Provider Demographics
NPI:1861673030
Name:KRUEGER, JOHN R (LP, LICSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:LP, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2390
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-2390
Mailing Address - Country:US
Mailing Address - Phone:320-650-1544
Mailing Address - Fax:320-650-1528
Practice Address - Street 1:157 ROOSEVELT RD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5481
Practice Address - Country:US
Practice Address - Phone:320-240-3324
Practice Address - Fax:320-240-3339
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0553103T00000X
MN37051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical