Provider Demographics
NPI:1114442233
Name:BRUCE, CHRISTOPHER D (COTA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
Last Name:BRUCE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:D
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:354 KINGS RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6030
Mailing Address - Country:US
Mailing Address - Phone:601-918-2659
Mailing Address - Fax:
Practice Address - Street 1:101 KIRKLAND ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-3205
Practice Address - Country:US
Practice Address - Phone:601-774-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA3256224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant