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General NPI Number Information
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NPI Number | 1124535281
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Entity Type | Individual
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Provider Name | HERBERT CLINTON-COOPER KRUEGER
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Gender | Male
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Dates
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Enumeration Date | 01/10/2018
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Last Update Date | 12/22/2020
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Provider Practice Location Address
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Address Line | 1613 M 139
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City | BENTON HARBOR
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State | MI
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Zip | 49022-5748
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Country | US
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Telephone | 269-934-1694
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Fax |
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Provider Business Mailing Address
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Address Line | 1485 M 139
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City | BENTON HARBOR
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State | MI
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Zip | 49022-5711
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Country | US
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Telephone | 269-925-0585
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6802089795
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License Number State | MI
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