Basic Information
| Provider Information | |||||||||
| NPI: | 1013361344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.ED, BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4210 MOCKINGBIRD CIR | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028683693 | ||||||||
| FaxNumber: | 8085248186 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N VINEYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968173950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085238188 | ||||||||
| FaxNumber: | 8085248186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-27429 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.