Provider Demographics
NPI:1619462678
Name:BRACKMAN, GRETA CULLEN (CG60872398)
Entity Type:Individual
Prefix:MS
First Name:GRETA
Middle Name:CULLEN
Last Name:BRACKMAN
Suffix:
Gender:F
Credentials:CG60872398
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 TACOMA AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1903
Mailing Address - Country:US
Mailing Address - Phone:253-320-5674
Mailing Address - Fax:
Practice Address - Street 1:1305 TACOMA AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1903
Practice Address - Country:US
Practice Address - Phone:253-320-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60872398101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor