Provider Demographics
NPI:1598799645
Name:CHESSEN, BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:CHESSEN
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 1:3355 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282-8223
Mailing Address - Country:US
Mailing Address - Phone:406-248-1126
Mailing Address - Fax:406-245-0948
Practice Address - Street 1:3355 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:CAMANO ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98282-8223
Practice Address - Country:US
Practice Address - Phone:406-248-1126
Practice Address - Fax:406-245-0948
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60894790103TC2200X
MTMT147103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0490425Medicaid