Provider Demographics
NPI:1336116375
Name:ATKINSON, BRUCE E (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:ATKINSON
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 1826
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-7524
Mailing Address - Country:US
Mailing Address - Phone:770-439-9353
Mailing Address - Fax:770-439-7090
Practice Address - Street 1:1830 WATER PL SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-7407
Practice Address - Country:US
Practice Address - Phone:770-439-9353
Practice Address - Fax:770-439-7090
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001400103TC0700X, 103T00000X, 106H00000X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00545069BMedicaid
40055OtherNATIONAL REGISTER