Provider Demographics
NPI:1609528355
Name:BRUCE, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BRUCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 N DAMEN AVE APT 409
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1471
Mailing Address - Country:US
Mailing Address - Phone:443-569-1106
Mailing Address - Fax:
Practice Address - Street 1:4829 N DAMEN AVE APT 409
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1471
Practice Address - Country:US
Practice Address - Phone:443-569-1106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health