Healthcare Provider Details

I. General information

NPI: 1003120510
Provider Name (Legal Business Name): REBECCA NICOLE BRUECK MSN RN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 N DETROIT ST
LAGRANGE IN
46761-1112
US

IV. Provider business mailing address

2621 E JEFFERSON ST
WARSAW IN
46580-3880
US

V. Phone/Fax

Practice location:
  • Phone: 260-499-3019
  • Fax: 260-499-3022
Mailing address:
  • Phone: 574-267-7169
  • Fax: 574-269-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704277738
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71017278A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: