Provider Demographics
NPI:1912591140
Name:BRUCKER, ANDREW
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:BRUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 HAUSER BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5636
Mailing Address - Country:US
Mailing Address - Phone:213-866-5173
Mailing Address - Fax:
Practice Address - Street 1:340 HAUSER BLVD APT 204
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5636
Practice Address - Country:US
Practice Address - Phone:213-866-5173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health