Basic Information
| Provider Information | |||||||||
| NPI: | 1922057694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNICKLE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PHD LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | CENTRACARE HEALTH PLAZA | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294977 | ||||||||
| FaxNumber: | 3206567058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | LP1975 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.