Provider Demographics
NPI:1255004156
Name:BRUCE, DYAMOND
Entity Type:Individual
Prefix:
First Name:DYAMOND
Middle Name:
Last Name:BRUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1771
Mailing Address - Country:US
Mailing Address - Phone:773-354-2346
Mailing Address - Fax:
Practice Address - Street 1:721 N LASALLE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:312-655-7167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty