Provider Demographics
NPI:1174672166
Name:BOLTUCH, BRUCE S (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:S
Last Name:BOLTUCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:BOLTUCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:88 WILLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6831
Mailing Address - Country:US
Mailing Address - Phone:201-666-7717
Mailing Address - Fax:201-666-7717
Practice Address - Street 1:88 WILLOW DRIVE
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-6831
Practice Address - Country:US
Practice Address - Phone:201-666-7717
Practice Address - Fax:201-666-7717
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1274103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJB0444127Medicare ID - Type Unspecified