Provider Demographics
NPI:1639701279
Name:HOLDER, BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:HOLDER
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 1:525 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46989-9101
Mailing Address - Country:US
Mailing Address - Phone:765-997-1945
Mailing Address - Fax:
Practice Address - Street 1:525 S MAIN ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:IN
Practice Address - Zip Code:46989-9101
Practice Address - Country:US
Practice Address - Phone:765-298-9315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000465A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty