Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 3906-123 | WI |
NPI | 1043376734 |
---|---|
Provider Name | Ted Terry Bruce |
First Address | Glendale, WI 53217 |
Second Address | Glendale, WI 53217 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2006 |
Last Update Date | 08/07/2007 |