Provider Demographics
NPI:1043221252
Name:MILLER BRUCKNER, ELISA SHAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:SHAWN
Last Name:MILLER BRUCKNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PELZ FARM CT
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-3275
Mailing Address - Country:US
Mailing Address - Phone:201-321-2956
Mailing Address - Fax:201-321-2956
Practice Address - Street 1:205 N FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1630
Practice Address - Country:US
Practice Address - Phone:201-321-2956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC468931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical