Basic Information
| Provider Information | |||||||||
| NPI: | 1871079665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUCKENBERG | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | ADRIAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2085 RUSTIN AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519557263 | ||||||||
| FaxNumber: | 9519557205 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094219380 | ||||||||
| FaxNumber: | 9094219392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2018 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 104512 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.