Provider Demographics
NPI:1902076698
Name:BRUESEWITZ, CRAIG ALAN (CLINICAL SUBSTANCE)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ALAN
Last Name:BRUESEWITZ
Suffix:
Gender:M
Credentials:CLINICAL SUBSTANCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 FOND DU LAC AVENUE
Mailing Address - Street 2:
Mailing Address - City:KEWASHUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040
Mailing Address - Country:US
Mailing Address - Phone:262-626-4166
Mailing Address - Fax:262-626-8431
Practice Address - Street 1:1421 FOND DU LAC AVENUE
Practice Address - Street 2:
Practice Address - City:KEWASHUM
Practice Address - State:WI
Practice Address - Zip Code:53040
Practice Address - Country:US
Practice Address - Phone:262-626-4166
Practice Address - Fax:262-626-8431
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2091132101Y00000X
WIDHS 75.14 #2598101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor