Provider Demographics
NPI:1548409329
Name:BRUCKER, ALEXANDER D (LCPC)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:D
Last Name:BRUCKER
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1640
Mailing Address - Country:US
Mailing Address - Phone:309-454-1770
Mailing Address - Fax:309-454-9257
Practice Address - Street 1:1100 BEECH ST STE 7
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1456
Practice Address - Country:US
Practice Address - Phone:309-454-1770
Practice Address - Fax:309-454-9257
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007128101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional