Provider Demographics
NPI:1720128523
Name:BRUSTER, ERIC J (PSYD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:BRUSTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S74W16775 JANESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-7742
Mailing Address - Country:US
Mailing Address - Phone:414-773-4312
Mailing Address - Fax:414-422-2188
Practice Address - Street 1:S74W16775 JANESVILLE RD
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150
Practice Address - Country:US
Practice Address - Phone:414-773-4312
Practice Address - Fax:414-422-2188
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00716103T00000X, 103TC0700X
IA00280103TH0100X
WI3597103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100083826Medicaid
IA420716337Medicaid
IA420716337Medicaid