MEDICARE: MS. TERI VIRGINIA KRULL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW 0130	AZ

General Provider Information

NPI Number	:	1023231594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERI VIRGINIA KRULL LCSW

Provider Business Mailing Address
First Line	:	718 W MONTE CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-7554
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2345 S ALMA SCHOOL RD
Second Line	:	110
City	:	MESA
State	:	AZ
Zip	:	85210-4011
Country	:	US
Telephone Number	:	480-917-7792
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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