Provider Demographics
NPI:1174180822
Name:KRUEGER INTEGRATIVE CARE, LLC
Entity Type:Organization
Organization Name:KRUEGER INTEGRATIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENCED PSYCHOLOGIST, DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TONICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCP
Authorized Official - Phone:619-865-9399
Mailing Address - Street 1:4467 NEW MARKET RD
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4915
Mailing Address - Country:US
Mailing Address - Phone:619-865-9399
Mailing Address - Fax:
Practice Address - Street 1:4893 PRINCE WILLIAM PKWY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5403
Practice Address - Country:US
Practice Address - Phone:850-565-9710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184949398OtherNPI 1