Provider Demographics
NPI:1508974478
Name:BRUCKELMEYER, ANN (LCSW, CADC)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:BRUCKELMEYER
Suffix:
Gender:F
Credentials:LCSW, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-7843
Mailing Address - Country:US
Mailing Address - Phone:630-545-0795
Mailing Address - Fax:630-545-0781
Practice Address - Street 1:195 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-7843
Practice Address - Country:US
Practice Address - Phone:630-545-0795
Practice Address - Fax:630-545-0781
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149009205101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL320100556OtherEIN NUMBER