Provider Demographics
NPI:1093530263
Name:KRUEGER TAYLOR, KASSIE
Entity type:Individual
Prefix:
First Name:KASSIE
Middle Name:
Last Name:KRUEGER TAYLOR
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:PO BOX 811
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-0811
Mailing Address - Country:US
Mailing Address - Phone:951-847-0861
Mailing Address - Fax:
Practice Address - Street 1:1382 BLUE OAKS BLVD STE 213
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7052
Practice Address - Country:US
Practice Address - Phone:877-412-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT147239101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health