Provider Demographics
NPI:1821109331
Name:WYMAN, BRUCE CHARLES (LPC, EDM, NCC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:CHARLES
Last Name:WYMAN
Suffix:
Gender:M
Credentials:LPC, EDM, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:RIXEYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22737-0373
Mailing Address - Country:US
Mailing Address - Phone:540-937-4923
Mailing Address - Fax:540-937-7680
Practice Address - Street 1:10391 GREYSON LN
Practice Address - Street 2:
Practice Address - City:RIXEYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22737-1730
Practice Address - Country:US
Practice Address - Phone:540-937-4923
Practice Address - Fax:540-937-7680
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003919101YM0800X, 101YP2500X, 106H00000X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4435897OtherCIGNA BEHAVIORAL
VAAS43-0001OtherCAREFIRST BLUECROSS BLUESHIELD
VA010375703Medicaid
VA11654016OtherCAQH