MEDICARE: KIMBERLY KRUSE MFT 88539, MFT15448

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	88539	CA
2	106H00000X	Marriage & Family Therapist	15448	AZ

General Provider Information

NPI Number	:	1750836912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY KRUSE MFT 88539, MFT15448

Provider Business Mailing Address
First Line	:	2532 N 4TH ST # 271
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-3712
Country	:	US
Telephone Number	:	818-493-1655
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 N JACKRABBIT LN
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001
Country	:	US
Telephone Number	:	818-493-1655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2016
Last Update Date	:	10/24/2022

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