Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 2174 | GA |
N | 103T00000X | Psychologist | 2174 | GA |
N | 103TC1900X | Counseling Psychologist | 2174 | GA |
NPI | 1104924620 |
---|---|
Provider Name | Judy Bruckner |
First Address | Bogart, GA 30622-2544 |
Second Address | Bogart, GA 30622-2544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 09/07/2007 |