Basic Information
| Provider Information | |||||||||
| NPI: | 1952385940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KURUSU | ||||||||
| FirstName: | TARO | ||||||||
| MiddleName: | AUGUSTUS | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6541 SPECKER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267155 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6541 SPECKER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267155 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY8365 | FL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X | 2316 | TN | N | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 680014816 | 01 | RAILROAD MEDICARE | OTHER | 4065356 | 01 | BCBS-TN | OTHER | 702017316 | 01 | CARITEN HEALTHCARE | OTHER | 476464000 | 01 | MAGELLAN | OTHER | TN0102 | 01 | JOHNDEERE HEALTHCARE | OTHER | 4039014 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 476464000 | 01 | AETNA | OTHER |