1831609098 NPI number — HEATHER MARIE BRUCKSCHEN LPC-IT, SAC-IT

Table of content: HEATHER MARIE BRUCKSCHEN LPC-IT, SAC-IT (NPI 1831609098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831609098 NPI number — HEATHER MARIE BRUCKSCHEN LPC-IT, SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUCKSCHEN
Provider First Name:
HEATHER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-IT, SAC-IT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANTONIEWICZ
Provider Other First Name:
HEATHER
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC-IT, SAC-IT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831609098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1823
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54221-1823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-663-1035
Provider Business Mailing Address Fax Number:
920-215-4918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3733 DEWEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANITOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54220-5844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-663-1035
Provider Business Practice Location Address Fax Number:
920-215-4918
Provider Enumeration Date:
10/02/2017

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: 101YM0800X , with the licence number:  3712-226 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 17957-130 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100074973 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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