Provider Demographics
NPI:1710938782
Name:OSBORNE, BRUCE WILLARD JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WILLARD
Last Name:OSBORNE
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:P O BOX 514
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031
Mailing Address - Country:US
Mailing Address - Phone:502-264-1514
Mailing Address - Fax:502-371-7550
Practice Address - Street 1:1800 ZHALE SMITH ROAD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031
Practice Address - Country:US
Practice Address - Phone:502-264-1514
Practice Address - Fax:502-371-7550
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1524101YP2500X
TNLPC0000000736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN283910000OtherMAGELLAN
TN4058210OtherBLUE CROSS BLUE SHIELD
TN230204OtherOPTUM EAP
TN283910000OtherAETNA
TN5441054Medicaid
TN11539066OtherCAQH