Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 2001003634 | MO |
Y | 103T00000X | Psychologist | 2001003634 | MO |
N | 103G00000X | Clinical Psychologist | LP-0999 | KS |
N | 103TC0700X | Clinical Psychologist | LP-0999 | KS |
N | 103TH0100X | Health Service | 2001003634 | MO |
NPI | 1306977426 |
---|---|
Provider Name | Dr. Bruce K. Manley |
First Address | Kansas City, MO 64151-3393 |
Second Address | Kansas City, MO 64151-5100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2007 |
Last Update Date | 16/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
27031028 | BLUE CROSS NON-PROVIDER # (01) | MO |