Provider Demographics
NPI:1073631420
Name:WHITING, BRUCE RANDOLPH (PHD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RANDOLPH
Last Name:WHITING
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 1:3131 LAKESTONE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-1120
Mailing Address - Country:US
Mailing Address - Phone:813-962-4701
Mailing Address - Fax:813-962-4701
Practice Address - Street 1:5221 EHRLICH RD STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2006
Practice Address - Country:US
Practice Address - Phone:813-960-8378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3260103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist