Provider Demographics
NPI:1275698920
Name:KROG, ERIC ANDREW (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ANDREW
Last Name:KROG
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-1738
Mailing Address - Country:US
Mailing Address - Phone:508-852-7795
Mailing Address - Fax:
Practice Address - Street 1:155 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-8142
Practice Address - Country:US
Practice Address - Phone:978-343-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4957101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health