Provider Demographics
NPI:1780902122
Name:BRUCKLIER, JOHN JOSEPH (MSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:BRUCKLIER
Suffix:
Gender:M
Credentials:MSW
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 1120
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-1120
Mailing Address - Country:US
Mailing Address - Phone:509-775-3341
Mailing Address - Fax:509-775-2937
Practice Address - Street 1:42 KLONDIKE
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-1266
Practice Address - Country:US
Practice Address - Phone:509-775-3341
Practice Address - Fax:509-775-2937
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00052748101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00053748OtherDEPARTMENT OF HEALTH