Provider Demographics
NPI:1588099550
Name:KRUSE, TREVOR RYAN
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:RYAN
Last Name:KRUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 S 9TH ST
Mailing Address - Street 2:APT E
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-1783
Mailing Address - Country:US
Mailing Address - Phone:541-250-2481
Mailing Address - Fax:
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-234-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health