Provider Demographics
NPI:1497086714
Name:ST. THOMAS, BRUCE CONRAD (ED,D)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CONRAD
Last Name:ST. THOMAS
Suffix:
Gender:M
Credentials:ED,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WESTBROOK ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1909
Mailing Address - Country:US
Mailing Address - Phone:207-772-4789
Mailing Address - Fax:
Practice Address - Street 1:545 WESTBROOK ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1909
Practice Address - Country:US
Practice Address - Phone:207-772-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC458101YP2500X
MEMF301106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist