Provider Demographics
NPI:1275279259
Name:CARPENTER, BRUCE EDWIN (LPC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWIN
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:LPC
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 331535
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76163-1535
Mailing Address - Country:US
Mailing Address - Phone:903-654-0784
Mailing Address - Fax:
Practice Address - Street 1:6607 SABROSA CT E
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-5251
Practice Address - Country:US
Practice Address - Phone:903-654-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73166101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX73166OtherLICENSED PROFESSIONAL COUNSELOR