Provider Demographics
NPI:1306834551
Name:BRUCE, RANDAL CLAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:CLAY
Last Name:BRUCE
Suffix:
Gender:M
Credentials:PHD
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 3380
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48333-3380
Mailing Address - Country:US
Mailing Address - Phone:248-624-8181
Mailing Address - Fax:855-624-8161
Practice Address - Street 1:37000 GRAND RIVER AVE STE 325
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2868
Practice Address - Country:US
Practice Address - Phone:248-624-8181
Practice Address - Fax:855-624-8161
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2023-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007332103TB0200X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0894440Medicare ID - Type Unspecified