1205039633 NPI number — MS. MARY THORNBURG KRUG MS, LPC

Table of content: MS. MARY THORNBURG KRUG MS, LPC (NPI 1205039633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205039633 NPI number — MS. MARY THORNBURG KRUG MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUG
Provider First Name:
MARY
Provider Middle Name:
THORNBURG
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205039633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 NE BROADWAY ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-1569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-449-9729
Provider Business Mailing Address Fax Number:
503-287-2801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 NE BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97232-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-449-9729
Provider Business Practice Location Address Fax Number:
503-287-2801
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  C 2231 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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