Provider Demographics
NPI:1063596567
Name:BRUCKNER, ELAINE J (PHD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:J
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 W WOOSTER ST
Mailing Address - Street 2:SUITE 124
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2643
Mailing Address - Country:US
Mailing Address - Phone:419-352-6666
Mailing Address - Fax:419-353-1117
Practice Address - Street 1:970 W WOOSTER ST
Practice Address - Street 2:SUITE 124
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2643
Practice Address - Country:US
Practice Address - Phone:419-352-6666
Practice Address - Fax:419-353-1117
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5040103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0220988Medicare ID - Type Unspecified
OHBRCP18715Medicare ID - Type Unspecified