Healthcare Provider Details

I. General information

NPI: 1558698357
Provider Name (Legal Business Name): KLINTON R. KROUSE HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GOSHEN RD
FORT WAYNE IN
46808-1493
US

IV. Provider business mailing address

PO BOX 497 2621 E. JEFFERSON ST.
WARSAW IN
46581-0497
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-3500
  • Fax: 260-471-4263
Mailing address:
  • Phone: 574-267-7169
  • Fax: 574-269-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001609A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042736A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: