Provider Demographics
NPI:1912236860
Name:BRUCK, SUZAN ANN (LMHC (LICENSED MENTA)
Entity Type:Individual
Prefix:MRS
First Name:SUZAN
Middle Name:ANN
Last Name:BRUCK
Suffix:
Gender:F
Credentials:LMHC (LICENSED MENTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CIRCLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577
Mailing Address - Country:US
Mailing Address - Phone:718-353-6798
Mailing Address - Fax:
Practice Address - Street 1:21 CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577
Practice Address - Country:US
Practice Address - Phone:718-353-6798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health