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General NPI Number Information
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NPI Number | 1801504923
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Entity Type | Individual
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Provider Name | LEAH M BRUECKNER ATC
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Gender | Female
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Dates
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Enumeration Date | 11/08/2022
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Last Update Date | 11/08/2022
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Provider Practice Location Address
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Address Line | 401 CHAFFER AVE
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City | ROXANA
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State | IL
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Zip | 62084-1125
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Country | US
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Telephone | 618-920-2452
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Fax |
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Provider Business Mailing Address
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Address Line | 312 CROSS CREEK DR
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City | BETHALTO
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State | IL
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Zip | 62010-2004
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Country | US
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Telephone | 618-920-2452
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096.001407
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License Number State | IL
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