Provider Demographics
NPI:1093033375
Name:MILLER-BRUCE, ANDREA E (PSYD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:MILLER-BRUCE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2851
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30031-2851
Mailing Address - Country:US
Mailing Address - Phone:404-354-4112
Mailing Address - Fax:404-377-7287
Practice Address - Street 1:805 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1870
Practice Address - Country:US
Practice Address - Phone:404-354-4112
Practice Address - Fax:404-377-6798
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003189103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12018036OtherCAQH: