MEDICARE: DONNA BRUCKNER, LCSW, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW003290	GA

General Provider Information

NPI Number	:	1215260153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONNA BRUCKNER, LCSW, LLC

Provider Business Mailing Address
First Line	:	2223 LASALLE DR
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-8149
Country	:	US
Telephone Number	:	770-645-6393
Fax Number	:

Provider Business Practice Location Address
First Line	:	4321 ATLANTA ST
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-2672
Country	:	US
Telephone Number	:	770-943-8277
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL SOCIAL WORKER
Name	:	MRS. DONNA BRUCKNER
Credential	:	L.C.S.W.
Telephone Number	:	770-645-6393

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/10/2009

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