Healthcare Provider Details

I. General information

NPI: 1861673030
Provider Name (Legal Business Name): JOHN R KRUEGER LP, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 ROOSEVELT RD STE 300
SAINT CLOUD MN
56301-5481
US

IV. Provider business mailing address

PO BOX 2390
SAINT CLOUD MN
56302-2390
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-3324
  • Fax: 320-240-3339
Mailing address:
  • Phone: 320-650-1544
  • Fax: 320-650-1528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0553
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3705
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: