Basic Information
| Provider Information | |||||||||
| NPI: | 1164850434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | COREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6650 CORPORATE CENTER PKWY APT 518 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047189607 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1809 E.BROADWAY ST. SUITE 122 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106S00000X | Y |
No ID Information.