Provider Demographics
NPI:1851452221
Name:BUNDY, BRUCE W (PSYD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:BUNDY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 SW NANCY WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3234
Mailing Address - Country:US
Mailing Address - Phone:541-382-0279
Mailing Address - Fax:541-382-6003
Practice Address - Street 1:1569 SW NANCY WAY STE 5
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3234
Practice Address - Country:US
Practice Address - Phone:541-382-0279
Practice Address - Fax:541-382-6003
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0752103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000TCHSPMedicare ID - Type Unspecified