Provider Demographics
NPI:1689851313
Name:RUCKTENWALD, ELIESE CHRISTINE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:ELIESE
Middle Name:CHRISTINE
Last Name:RUCKTENWALD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W BROWN DEER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1220
Mailing Address - Country:US
Mailing Address - Phone:414-540-1270
Mailing Address - Fax:414-540-2171
Practice Address - Street 1:3900 W BROWN DEER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1220
Practice Address - Country:US
Practice Address - Phone:414-540-1270
Practice Address - Fax:414-540-2171
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7639-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical