Provider Demographics
NPI:1356459127
Name:JAMES, BRUCE MICHAEL (EDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MICHAEL
Last Name:JAMES
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 MCCONVILLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4534
Mailing Address - Country:US
Mailing Address - Phone:434-237-4652
Mailing Address - Fax:
Practice Address - Street 1:1120 MCCONVILLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4534
Practice Address - Country:US
Practice Address - Phone:434-237-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07180000118101YA0400X
VA0701-002204101YP2500X
VA0717-000248106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5410142Medicaid