Basic Information
Provider Information
NPI: 1033559224
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRUECK
FirstName: KERSTIN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MA, ALC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9 OFFICE PARK CIR STE 109
Address2:  
City: MOUNTAIN BRK
State: AL
PostalCode: 352232501
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 9 OFFICE PARK CIR STE 109
Address2:  
City: MOUNTAIN BRK
State: AL
PostalCode: 352232501
CountryCode: US
TelephoneNumber: 2517519205
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/02/2013
LastUpdateDate: 07/15/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X  Y Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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