Basic Information
| Provider Information | |||||||||
| NPI: | 1841787363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | NATHAN | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST STE 1800 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913677807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 780 MCARDLE DR STE A | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600148155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7792206262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-29915 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 11829915 | 01 | IL | ALL COMMERCIAL PAYORS | OTHER |