Provider Demographics
NPI:1497377568
Name:KRUEGER, MARYSA
Entity Type:Individual
Prefix:
First Name:MARYSA
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19820 N 13TH AVE UNIT 206
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4312
Mailing Address - Country:US
Mailing Address - Phone:602-300-1190
Mailing Address - Fax:
Practice Address - Street 1:5040 E. SHEA BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor