Provider Demographics
NPI:1063802403
Name:BRUCE, LEAH M (LPC, SAC)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LPC, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 N 117TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4128
Mailing Address - Country:US
Mailing Address - Phone:414-337-8988
Mailing Address - Fax:414-479-0230
Practice Address - Street 1:3040 N 117TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4128
Practice Address - Country:US
Practice Address - Phone:414-337-8988
Practice Address - Fax:414-479-0230
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6371-125101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI17306-130OtherWISCONSIN LICENSE
WI6371-125OtherLICENSED PROFESSIONAL COUNSELOR
WI1063802403Medicaid