Provider Demographics
NPI:1346385846
Name:BRUCKNER, DONNA (LCSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name: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 1:2223 LASALLE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8149
Mailing Address - Country:US
Mailing Address - Phone:678-492-1008
Mailing Address - Fax:
Practice Address - Street 1:3750 PALLADIAN VILLAGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-8200
Practice Address - Country:US
Practice Address - Phone:678-492-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0032901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical