Provider Demographics
NPI:1114687407
Name:BRUYETTE, MANDIE LYNN (SAC, APSW)
Entity Type:Individual
Prefix:MRS
First Name:MANDIE
Middle Name:LYNN
Last Name:BRUYETTE
Suffix:
Gender:F
Credentials:SAC, APSW
Other - Prefix:MRS
Other - First Name:MANDIE
Other - Middle Name:LYNN
Other - Last Name:MARTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APSW, SAC
Mailing Address - Street 1:19407 ROCK POINTE WAY UNIT 201
Mailing Address - Street 2:
Mailing Address - City:LANNON
Mailing Address - State:WI
Mailing Address - Zip Code:53046-2700
Mailing Address - Country:US
Mailing Address - Phone:715-773-2916
Mailing Address - Fax:
Practice Address - Street 1:10012 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1338
Practice Address - Country:US
Practice Address - Phone:414-810-4844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16622-131101YA0400X
WI132882-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)