Provider Demographics
NPI:1952385940
Name:KURUSU, TARO AUGUSTUS (PHD)
Entity Type:Individual
Prefix:
First Name:TARO
Middle Name:AUGUSTUS
Last Name:KURUSU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6541 SPECKER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4263
Mailing Address - Country:US
Mailing Address - Phone:719-526-7155
Mailing Address - Fax:
Practice Address - Street 1:6541 SPECKER AVE
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4263
Practice Address - Country:US
Practice Address - Phone:719-526-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8365103TC0700X
TN2316103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
680014816OtherRAILROAD MEDICARE
4065356OtherBCBS-TN
702017316OtherCARITEN HEALTHCARE
476464000OtherMAGELLAN
TN0102OtherJOHNDEERE HEALTHCARE
4039014OtherBLUE CROSS BLUE SHIELD
476464000OtherAETNA
TN3982376Medicare PIN
476464000OtherAETNA
TN0102OtherJOHNDEERE HEALTHCARE