Provider Demographics
NPI:1922194737
Name:BRUETT, TERRILL LEWIS (EDD)
Entity Type:Individual
Prefix:
First Name:TERRILL
Middle Name:LEWIS
Last Name:BRUETT
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:TERRILL
Other - Middle Name:LEWIS
Other - Last Name:BRUETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:405 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1327
Mailing Address - Country:US
Mailing Address - Phone:262-242-9405
Mailing Address - Fax:262-544-6377
Practice Address - Street 1:2717 GRANDVIEW BLVD SUITE 303
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-544-6486
Practice Address - Fax:262-544-6377
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI480-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist