Provider Demographics
NPI:1558698357
Name:KROUSE, KLINTON R (HSPP)
Entity Type:Individual
Prefix:
First Name:KLINTON
Middle Name:R
Last Name:KROUSE
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:2621 E. JEFFERSON ST.
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46581-0497
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-269-5573
Practice Address - Street 1:2100 GOSHEN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-1493
Practice Address - Country:US
Practice Address - Phone:260-471-3500
Practice Address - Fax:260-471-4263
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001609A101YM0800X
IN20042736A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health