Basic Information
| Provider Information | |||||||||
| NPI: | 1336392877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WACKER | ||||||||
| FirstName: | DRUSILLA | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193142536 | ||||||||
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| Practice Location | |||||||||
| Address1: | 875 W MORENO AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726200 | ||||||||
| FaxNumber: | 7195726299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 03/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 178003750 | IL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 6284 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.