Healthcare Provider Details

I. General information

NPI: 1265068340
Provider Name (Legal Business Name): JOHN CROUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10 STE 500
BROOKLYN CENTER MN
55429-3068
US

IV. Provider business mailing address

737 N VAN BUREN WAY
HOPKINS MN
55343-8146
US

V. Phone/Fax

Practice location:
  • Phone: 612-548-1796
  • Fax:
Mailing address:
  • Phone: 701-330-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC02400
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: