Provider Demographics
NPI:1184067506
Name:BRUECKNER, SHANNON (MFT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRUECKNER
Suffix:
Gender:F
Credentials:MFT
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 20554
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94620-0554
Mailing Address - Country:US
Mailing Address - Phone:415-710-9495
Mailing Address - Fax:
Practice Address - Street 1:2930 CAMINO DIABLO
Practice Address - Street 2:SUITE 310
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3986
Practice Address - Country:US
Practice Address - Phone:415-710-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist