Provider Demographics
NPI:1255696027
Name:BRUCKMAN, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BRUCKMAN
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 1:7791 N GOSHEN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-8879
Mailing Address - Country:US
Mailing Address - Phone:260-750-6344
Mailing Address - Fax:765-644-0500
Practice Address - Street 1:800 MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1545
Practice Address - Country:US
Practice Address - Phone:765-644-0500
Practice Address - Fax:765-644-0510
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001368A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist