Provider Demographics
NPI:1053467563
Name:KRUGER, ELLEN RUTH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:RUTH
Last Name:KRUGER
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 1:49 HAMMOND PL
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-3415
Mailing Address - Country:US
Mailing Address - Phone:781-932-0559
Mailing Address - Fax:781-395-2909
Practice Address - Street 1:84 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3844
Practice Address - Country:US
Practice Address - Phone:781-393-0009
Practice Address - Fax:781-395-2909
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105528101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKR-P03900Medicare ID - Type Unspecified