Provider Demographics
NPI:1225578263
Name:KRUSE, ERIC C (LMFT #116204)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:KRUSE
Suffix:
Gender:M
Credentials:LMFT #116204
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 W WASHINGTON BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5176
Mailing Address - Country:US
Mailing Address - Phone:310-729-4362
Mailing Address - Fax:
Practice Address - Street 1:13101 W WASHINGTON BLVD STE 124
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5176
Practice Address - Country:US
Practice Address - Phone:310-729-4362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116204106H00000X
CAIMF 96249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist