Provider Demographics
NPI:1194543090
Name:BRUCKNER, ADRIANNE RENEE
Entity type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:RENEE
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7463A HARDSCRAPPLE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-1314
Mailing Address - Country:US
Mailing Address - Phone:314-934-4472
Mailing Address - Fax:
Practice Address - Street 1:9374 OLIVE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:OLIVETTE
Practice Address - State:MO
Practice Address - Zip Code:63132-3253
Practice Address - Country:US
Practice Address - Phone:314-934-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT-24-353451106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician