Provider Demographics
NPI:1477703635
Name:GORDEN, BRUCE LANE (MFT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:LANE
Last Name:GORDEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 CAMINO DEL RIO S
Mailing Address - Street 2:STE 250
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3607
Mailing Address - Country:US
Mailing Address - Phone:619-298-8722
Mailing Address - Fax:
Practice Address - Street 1:2333 CAMINO DEL RIO S
Practice Address - Street 2:STE 250
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3607
Practice Address - Country:US
Practice Address - Phone:619-298-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT17833106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist