Provider Demographics
NPI:1972828036
Name:KRUSE, MARY JANE (MA, CAC III)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:KRUSE
Suffix:
Gender:F
Credentials:MA, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 W CASPER DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:328 W CASPER DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-2818
Practice Address - Country:US
Practice Address - Phone:719-569-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5214OtherCAC III CERTIFICATION NUMBER