Provider Demographics
NPI:1225153158
Name:KRUG, WALTER JOHN (MA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:JOHN
Last Name:KRUG
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4145 SPIREA DR APT C
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-392-6148
Mailing Address - Fax:
Practice Address - Street 1:3311 BURNT MILL DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2654
Practice Address - Country:US
Practice Address - Phone:910-251-5817
Practice Address - Fax:910-251-2652
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0590103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities