Provider Demographics
NPI:1750653945
Name:BRUCE, LAVERNE (LCAS-P)
Entity Type:Individual
Prefix:MR
First Name:LAVERNE
Middle Name:
Last Name:BRUCE
Suffix:
Gender:M
Credentials:LCAS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E ELIZABETH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4472
Mailing Address - Country:US
Mailing Address - Phone:252-619-0319
Mailing Address - Fax:
Practice Address - Street 1:504 E ELIZABETH ST STE 1
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4472
Practice Address - Country:US
Practice Address - Phone:252-619-0319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)