=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750836912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY KRUSE MFT 88539, MFT15448
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2016
-----------------------------------------------------
Last Update Date | 10/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3225 N JACKRABBIT LN
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-493-1655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2532 N 4TH ST # 271
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86004-3712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-493-1655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 88539
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 15448
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------