Provider Demographics
NPI:1760725642
Name:KRUSE, TYLANE
Entity Type:Individual
Prefix:
First Name:TYLANE
Middle Name:
Last Name:KRUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4929 DARCY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-7622
Mailing Address - Country:US
Mailing Address - Phone:858-264-5858
Mailing Address - Fax:858-649-6012
Practice Address - Street 1:4929 DARCY WOODS LN
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7622
Practice Address - Country:US
Practice Address - Phone:919-810-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-42061103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst