Healthcare Provider Details

I. General information

NPI: 1861357931
Provider Name (Legal Business Name): RYAN KRUSE LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 N SAN FRANCISCO ST
FLAGSTAFF AZ
86001-3254
US

IV. Provider business mailing address

914 N SAN FRANCISCO ST
FLAGSTAFF AZ
86001-3254
US

V. Phone/Fax

Practice location:
  • Phone: 623-695-7980
  • Fax:
Mailing address:
  • Phone: 623-695-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-23489
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: