Provider Demographics
NPI:1538130406
Name:WEBSTER, BRUCE DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DOUGLAS
Last Name:WEBSTER
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 1:20101 SW BIRCH ST
Mailing Address - Street 2:ST # 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1748
Mailing Address - Country:US
Mailing Address - Phone:949-851-9102
Mailing Address - Fax:949-786-0112
Practice Address - Street 1:20101 SW BIRCH ST
Practice Address - Street 2:ST # 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1748
Practice Address - Country:US
Practice Address - Phone:949-851-9102
Practice Address - Fax:949-786-0112
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7847103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP7847Medicare ID - Type Unspecified