Provider Demographics
NPI:1770669004
Name:BRUCE, ELLEN GORDEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:GORDEN
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:RENEE
Other - Last Name:GORDEN BRUCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:1308 ATWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-4936
Mailing Address - Country:US
Mailing Address - Phone:401-942-8449
Mailing Address - Fax:401-232-2201
Practice Address - Street 1:1308 ATWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-4936
Practice Address - Country:US
Practice Address - Phone:401-942-8449
Practice Address - Fax:401-232-2201
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW007211041C0700X
MA1075091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
260561OtherBEACON HEALTH STRATEGIC
RI38768OtherBCBS OF RI
RI407697OtherBLUE CHIP
6242099OtherUNITED HEALTH