Healthcare Provider Details

I. General information

NPI: 1417407297
Provider Name (Legal Business Name): CORY R KRUEGER MS, LPC-IT, SAC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 ANNEX RD
JEFFERSON WI
53549-9803
US

IV. Provider business mailing address

W7210 COUNTY ROAD V
LAKE MILLS WI
53551-9645
US

V. Phone/Fax

Practice location:
  • Phone: 920-674-3105
  • Fax:
Mailing address:
  • Phone: 920-648-5613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17863-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3039-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: