Provider Demographics
NPI:1437344470
Name:KRUCKEBERG, ANDREW D (BSE)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:KRUCKEBERG
Suffix:
Gender:M
Credentials:BSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-3290
Mailing Address - Country:US
Mailing Address - Phone:714-668-8498
Mailing Address - Fax:
Practice Address - Street 1:2416 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-3290
Practice Address - Country:US
Practice Address - Phone:714-668-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health