Provider Demographics
NPI:1427156520
Name:KRUSE, DWAYNE ALLEN (MA)
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:ALLEN
Last Name:KRUSE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 N MARSHALL WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TOMBSTONE
Mailing Address - State:AZ
Mailing Address - Zip Code:85638-6114
Mailing Address - Country:US
Mailing Address - Phone:520-678-1115
Mailing Address - Fax:
Practice Address - Street 1:1621 N MARSHALL WHITE RD
Practice Address - Street 2:
Practice Address - City:TOMBSTONE
Practice Address - State:AZ
Practice Address - Zip Code:85638-6114
Practice Address - Country:US
Practice Address - Phone:520-678-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
WALF61171041106H00000X
AZLMFT-15582106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor