Provider Demographics
NPI:1710512595
Name:BRUCKNER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N FERN ABBEY LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8981
Mailing Address - Country:US
Mailing Address - Phone:919-647-4763
Mailing Address - Fax:
Practice Address - Street 1:111 N FERN ABBEY LN
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8981
Practice Address - Country:US
Practice Address - Phone:919-647-4763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12968225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist