Provider Demographics
NPI:1497243836
Name:BRUCKNER, SHANNON (LCSW, CAADC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:LCSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3462
Mailing Address - Country:US
Mailing Address - Phone:864-659-0543
Mailing Address - Fax:
Practice Address - Street 1:119 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3462
Practice Address - Country:US
Practice Address - Phone:864-659-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0263101YA0400X
GACSW0062701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)