Provider Demographics
NPI:1003906348
Name:BROTTER, BRUCE RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:RICHARD
Last Name:BROTTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-3508
Mailing Address - Country:US
Mailing Address - Phone:914-693-2190
Mailing Address - Fax:
Practice Address - Street 1:5 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-3508
Practice Address - Country:US
Practice Address - Phone:914-693-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO30945-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N24651Medicare PIN
NYN24651Medicare ID - Type UnspecifiedNY MEDICARE PROVIDER #