Provider Demographics
NPI:1366745416
Name:KRUSE, KIMBERLY
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:KRUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RICHLAND MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6863
Mailing Address - Country:US
Mailing Address - Phone:803-434-4838
Mailing Address - Fax:803-434-4852
Practice Address - Street 1:11 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6863
Practice Address - Country:US
Practice Address - Phone:803-434-4838
Practice Address - Fax:803-434-4852
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1158103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical