Provider Demographics
NPI:1174293658
Name:DEBRUIN, MICHAEL (SAC-IT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEBRUIN
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S GLENRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3905
Mailing Address - Country:US
Mailing Address - Phone:414-552-8427
Mailing Address - Fax:
Practice Address - Street 1:201 S GLENRIDGE CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3905
Practice Address - Country:US
Practice Address - Phone:414-552-8427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19245-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)