Healthcare Provider Details

I. General information

NPI: 1144801598
Provider Name (Legal Business Name): NOLAN TRAVIS KRUEGER M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2021
Last Update Date: 04/17/2021
Certification Date: 04/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT WAY
BERKELEY CA
94720-4301
US

IV. Provider business mailing address

1100 E 32ND ST APT 109
AUSTIN TX
78722-2252
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-9494
  • Fax:
Mailing address:
  • Phone: 925-408-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: