MEDICARE: BILL BRACKER PSYD PA

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	103TC0700X	Clinical Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0006L	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1518107846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BILL BRACKER PSYD PA

Provider Business Mailing Address
First Line	:	915 MIDDLE RIVER DRIVE
Second Line	:	SUITE 307
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3560
Country	:	US
Telephone Number	:	954-566-2166
Fax Number	:	954-566-1186

Provider Business Practice Location Address
First Line	:	915 MIDDLE RIVER DRIVE
Second Line	:	SUITE 307
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3560
Country	:	US
Telephone Number	:	954-566-2166
Fax Number	:	954-566-1186

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM BRACKER JR.
Credential	:	PSY.D.
Telephone Number	:	95456621166

Provider Enumeration Date	:	02/26/2009
Last Update Date	:	10/15/2011

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