Provider Demographics
NPI:1215260153
Name:DONNA BRUCKNER, LCSW, LLC
Entity type:Organization
Organization Name:DONNA BRUCKNER, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-645-6393
Mailing Address - Street 1:2223 LASALLE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8149
Mailing Address - Country:US
Mailing Address - Phone:770-645-6393
Mailing Address - Fax:
Practice Address - Street 1:4321 ATLANTA ST
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2672
Practice Address - Country:US
Practice Address - Phone:770-943-8277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0032901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty