Provider Demographics
NPI:1073640736
Name:KRUEGER, MARI ANN (LPC)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:ANN
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:ANNE
Other - Last Name:HOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 282
Mailing Address - Street 2:
Mailing Address - City:BLACK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54106-0282
Mailing Address - Country:US
Mailing Address - Phone:920-385-5076
Mailing Address - Fax:866-327-3295
Practice Address - Street 1:404 N MAIN ST STE 612
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4953
Practice Address - Country:US
Practice Address - Phone:920-385-1420
Practice Address - Fax:866-327-3295
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3465 125101YM0800X, 101YP2500X
WI106595030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43595200Medicaid