Provider Demographics
NPI:1669744678
Name:KATHLEEN A KRUSE LCSW PC
Entity type:Organization
Organization Name:KATHLEEN A KRUSE LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-233-2550
Mailing Address - Street 1:1011 W LORAS DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6900
Mailing Address - Country:US
Mailing Address - Phone:815-233-2550
Mailing Address - Fax:
Practice Address - Street 1:1011 W LORAS DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6900
Practice Address - Country:US
Practice Address - Phone:815-233-2550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149007392104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty