Provider Demographics
NPI:1528327343
Name:HIRSCH KRUSE, FABIANE (PHD)
Entity type:Individual
Prefix:
First Name:FABIANE
Middle Name:
Last Name:HIRSCH KRUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:FABIANE
Other - Middle Name:
Other - Last Name:HIRSCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1011 N CRAYCROFT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-7309
Mailing Address - Country:US
Mailing Address - Phone:520-730-8428
Mailing Address - Fax:520-300-8328
Practice Address - Street 1:1011 N CRAYCROFT RD
Practice Address - Street 2:SUITE 301
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-7309
Practice Address - Country:US
Practice Address - Phone:520-730-8428
Practice Address - Fax:520-300-8328
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP#1636235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ713722Medicaid