Provider Demographics
NPI:1548279409
Name:KRUIS, EDWARD G (CMHC)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:G
Last Name:KRUIS
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4956
Mailing Address - Country:US
Mailing Address - Phone:505-527-2928
Mailing Address - Fax:
Practice Address - Street 1:1445 PECOS ST.
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:505-650-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0078221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM94876860Medicaid