Provider Demographics
NPI:1033862651
Name:COLERIDER-KRUGH, GLENNA (LICSW)
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:
Last Name:COLERIDER-KRUGH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5329 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1733
Mailing Address - Country:US
Mailing Address - Phone:626-676-5080
Mailing Address - Fax:
Practice Address - Street 1:310 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3218
Practice Address - Country:US
Practice Address - Phone:889-861-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN295511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical