Provider Demographics
NPI:1770011413
Name:KRUSE, CORISSA RAE
Entity Type:Individual
Prefix:
First Name:CORISSA
Middle Name:RAE
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 1:12823 OAK GROVE DR
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-8414
Mailing Address - Country:US
Mailing Address - Phone:218-686-0188
Mailing Address - Fax:
Practice Address - Street 1:115 VIVIAN ST W
Practice Address - Street 2:
Practice Address - City:PARK RIVER
Practice Address - State:ND
Practice Address - Zip Code:58270-4540
Practice Address - Country:US
Practice Address - Phone:701-284-4570
Practice Address - Fax:701-284-4581
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2011225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist