Provider Demographics
NPI:1699553016
Name:BRUCKS, BRYAN LINN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:LINN
Last Name:BRUCKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11925 ANTELOPE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-9736
Mailing Address - Country:US
Mailing Address - Phone:121-846-4823
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY COMMONS DR STE F-3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6432
Practice Address - Country:US
Practice Address - Phone:218-464-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-62844101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty