Healthcare Provider Details

I. General information

NPI: 1528901048
Provider Name (Legal Business Name): LINCOLN DEAN KROG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W FERN DR
FULLERTON CA
92833-2331
US

IV. Provider business mailing address

731 E LAVENDER WAY
AZUSA CA
91702-6294
US

V. Phone/Fax

Practice location:
  • Phone: 714-447-7710
  • Fax:
Mailing address:
  • Phone: 509-774-8299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: