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General NPI Number Information
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NPI Number | 1528182789
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Entity Type | Organization
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Legal Business Name | JUDY A. BRUCKNER, PH.D., P.C.
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 01/24/2023
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Provider Practice Location Address
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Address Line | 1551 JENNINGS MILL RD UNIT 2000B
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City | WATKINSVILLE
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State | GA
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Zip | 30677-7252
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Country | US
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Telephone | 706-316-9095
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Fax | 706-353-8948
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Provider Business Mailing Address
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Address Line | 1551 JENNINGS MILL RD UNIT 2000B
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City | WATKINSVILLE
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State | GA
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Zip | 30677-7252
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Country | US
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Telephone | 706-316-9095
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Fax | 706-353-8948
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUDY BRUCKNER
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Credential | PH.D.
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Telephone | 706-316-9095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY002174
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License Number State | GA
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