Provider Demographics
NPI:1760545909
Name:BRUCKERHOFF, VICKIE R (LPC)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:R
Last Name:BRUCKERHOFF
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-0468
Mailing Address - Country:US
Mailing Address - Phone:573-883-4402
Mailing Address - Fax:573-883-4472
Practice Address - Street 1:HWY 61 & 32
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670
Practice Address - Country:US
Practice Address - Phone:573-883-4402
Practice Address - Fax:573-883-4472
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003003970101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor