Provider Demographics
NPI:1871642744
Name:BRUSS, DIANNA LEIGH (LPC)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:LEIGH
Last Name:BRUSS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:DEDE
Other - Middle Name:
Other - Last Name:BRUSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:2300 RIVERSIDE DR STE 124
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-1900
Mailing Address - Country:US
Mailing Address - Phone:920-309-6861
Mailing Address - Fax:
Practice Address - Street 1:2300 RIVERSIDE DR STE 124
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1900
Practice Address - Country:US
Practice Address - Phone:920-309-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4111-125101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871642744Medicaid
WI100001117Medicaid