Provider Demographics
NPI:1720539836
Name:MORCKEL, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MORCKEL
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 1:3305 GREENWICH ANGLING RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:OH
Mailing Address - Zip Code:44837-9443
Mailing Address - Country:US
Mailing Address - Phone:419-752-5021
Mailing Address - Fax:419-752-8705
Practice Address - Street 1:3305 GREENWICH ANGLING RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:OH
Practice Address - Zip Code:44837-9443
Practice Address - Country:US
Practice Address - Phone:419-752-5021
Practice Address - Fax:419-752-8705
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUA1005143103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH16360Medicaid