1417407297 NPI number — CORY R KRUEGER MS, LPC-IT, SAC-IT

Table of content: CORY R KRUEGER MS, LPC-IT, SAC-IT (NPI 1417407297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417407297 NPI number — CORY R KRUEGER MS, LPC-IT, SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUEGER
Provider First Name:
CORY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC-IT, SAC-IT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417407297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W7210 COUNTY ROAD V
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MILLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53551-9645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-648-5613
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1541 ANNEX RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53549-9803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-674-3105
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  17863-130 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 3039-226 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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