Provider Demographics
NPI:1124535281
Name:KRUEGER, HERBERT CLINTON-COOPER
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:CLINTON-COOPER
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 M 139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-5711
Mailing Address - Country:US
Mailing Address - Phone:269-925-0585
Mailing Address - Fax:
Practice Address - Street 1:1613 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5748
Practice Address - Country:US
Practice Address - Phone:269-934-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089795104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker