Provider Demographics
NPI:1346383411
Name:BRUCKLACHER, LINDA (MFT)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:BRUCKLACHER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-0096
Mailing Address - Country:US
Mailing Address - Phone:209-755-1464
Mailing Address - Fax:209-755-1470
Practice Address - Street 1:265 WEST ST. CHARLES STREET
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-755-1464
Practice Address - Fax:209-755-1470
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37404101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor