Healthcare Provider Details

I. General information

NPI: 1083973234
Provider Name (Legal Business Name): TANGALA KROUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 COPPER TREE CT
O FALLON MO
63368-6339
US

IV. Provider business mailing address

138 HOLLYLEAF DR
BALLWIN MO
63021-6545
US

V. Phone/Fax

Practice location:
  • Phone: 636-265-0407
  • Fax:
Mailing address:
  • Phone: 319-360-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2012001900
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: