Provider Demographics
NPI:1679069280
Name:KRUEGER, MALLORIE (MSCP)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:
Other - Last Name:DAZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSCP
Mailing Address - Street 1:3904 CLAREMONT PL
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4314
Mailing Address - Country:US
Mailing Address - Phone:412-445-6870
Mailing Address - Fax:
Practice Address - Street 1:3920 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5343
Practice Address - Country:US
Practice Address - Phone:304-748-3768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health