Basic Information
| Provider Information | |||||||||
| NPI: | 1740220334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUSE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRUSE | ||||||||
| OtherFirstName: | J. | ||||||||
| OtherMiddleName: | RONALD | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2311 KILEY WAY | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730343428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059428888 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3832 N MERIDIAN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059428888 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 156 | OK | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0100X | 156 | OK | N | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 731154494001 | 01 | OK | BCBS INSURANCE | OTHER | 4251316 | 01 | OK | AETNA INSURANCE | OTHER |