Provider Demographics
NPI:1154472728
Name:BRUCKER, PENNY (PHD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5428 SILK OAK DRIVE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564
Mailing Address - Country:US
Mailing Address - Phone:630-809-2180
Mailing Address - Fax:630-219-3664
Practice Address - Street 1:24024 WEST BRANCASTER DRIVE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564
Practice Address - Country:US
Practice Address - Phone:630-809-2180
Practice Address - Fax:630-219-3664
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000599106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist