Healthcare Provider Details

I. General information

NPI: 1871079665
Provider Name (Legal Business Name): SEAN ADRIAN KRUCKENBERG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

IV. Provider business mailing address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

V. Phone/Fax

Practice location:
  • Phone: 909-808-0967
  • Fax:
Mailing address:
  • Phone: 909-808-0967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW121455
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121455
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number104512
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104512
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: