Provider Demographics
NPI:1790852622
Name:CRUSE, CAROLYN J (PSYD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:CRUSE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-8103
Mailing Address - Country:US
Mailing Address - Phone:214-828-2603
Mailing Address - Fax:214-828-4954
Practice Address - Street 1:5501 BRYAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-8103
Practice Address - Country:US
Practice Address - Phone:214-828-2603
Practice Address - Fax:214-828-4954
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33253103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185673401Medicaid