Provider Demographics
NPI:1831609098
Name:BRUCKSCHEN, HEATHER MARIE (LPC-IT, SAC-IT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:BRUCKSCHEN
Suffix:
Gender:F
Credentials:LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:ANTONIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC-IT, SAC-IT
Mailing Address - Street 1:PO BOX 1823
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1823
Mailing Address - Country:US
Mailing Address - Phone:920-663-1035
Mailing Address - Fax:920-215-4918
Practice Address - Street 1:3733 DEWEY ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5844
Practice Address - Country:US
Practice Address - Phone:920-663-1035
Practice Address - Fax:920-215-4918
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3712-226101YM0800X
WI17957-130101YM0800X
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100074973Medicaid