Provider Demographics
NPI:1841692811
Name:KRUEGER, LEA (CADCII, QMHP)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:CADCII, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-4179
Mailing Address - Fax:541-265-4194
Practice Address - Street 1:4422 NE DEVILS LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-5000
Practice Address - Country:US
Practice Address - Phone:541-265-4947
Practice Address - Fax:541-994-0261
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OR17-02-19101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator