Provider Demographics
NPI:1235275827
Name:ANDERSON, BRUCE G (CLINICAL PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CLINICAL PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EAST ST
Mailing Address - Street 2:LYCOMING CLINTON JOINDER BOARD
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-326-9895
Mailing Address - Fax:
Practice Address - Street 1:200 EAST ST
Practice Address - Street 2:LYCOMING CLINTON JOINDER BOARD
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-326-9895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004649L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist