Provider Demographics
NPI:1689994212
Name:BATES, BRUCE WALLACE (MFT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WALLACE
Last Name:BATES
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 E MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3202
Mailing Address - Country:US
Mailing Address - Phone:310-579-5002
Mailing Address - Fax:
Practice Address - Street 1:1304 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-3202
Practice Address - Country:US
Practice Address - Phone:310-579-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-05
Last Update Date:2010-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36597106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist