Provider Demographics
NPI:1861584625
Name:BRUSCA, BETTINE (LCSW)
Entity type:Individual
Prefix:
First Name:BETTINE
Middle Name:
Last Name:BRUSCA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LAKEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5576
Mailing Address - Country:US
Mailing Address - Phone:630-377-7292
Mailing Address - Fax:
Practice Address - Street 1:27W350 HIGH LAKE RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1262
Practice Address - Country:US
Practice Address - Phone:630-933-4672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2207757OtherBLUE CROSS BLUE SHIELD
IL384981Medicare ID - Type UnspecifiedMEDICARE
ILS1617Medicare UPIN