Basic Information
| Provider Information | |||||||||
| NPI: | 1932224052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1109 WESLEY AVE | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603042021 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1023 BURLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WESTERN SPRINGS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605581516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083540826 | ||||||||
| FaxNumber: | 7083540867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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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 | 103T00000X | 071004983 | IL | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.