Basic Information
| Provider Information | |||||||||
| NPI: | 1063802403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | SAC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848200 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848200 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2015 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | 6371-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6371-125 | 01 | WI | LICENSED PROFESSIONAL COUNSELOR | OTHER | 17306-130 | 01 | WI | WISCONSIN LICENSE | OTHER | 100049814 | 05 | WI | MEDICAID |