Provider Demographics
NPI:1053932228
Name:BRUCKMAN, ALLISON RAE (RBT)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:RAE
Last Name:BRUCKMAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 169TH ST # 2
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-2038
Mailing Address - Country:US
Mailing Address - Phone:773-484-3119
Mailing Address - Fax:
Practice Address - Street 1:938 169TH ST # 2
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-2038
Practice Address - Country:US
Practice Address - Phone:773-484-3119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-66875106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty