Provider Demographics
NPI:1750836912
Name:KRUSE, KIMBERLY (MFT 88539, MFT15448)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KRUSE
Suffix:
Gender:F
Credentials:MFT 88539, MFT15448
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 N 4TH ST # 271
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-3712
Mailing Address - Country:US
Mailing Address - Phone:818-493-1655
Mailing Address - Fax:
Practice Address - Street 1:3225 N JACKRABBIT LN
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:818-493-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88539106H00000X
AZ15448106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist