Provider Demographics
NPI:1861857419
Name:NIELS, BRUCE (LPT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:NIELS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12440 EAST NORWALK BOULEVARD
Mailing Address - Street 2:SUITE 3020
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-9331
Mailing Address - Country:US
Mailing Address - Phone:562-864-7821
Mailing Address - Fax:562-864-7864
Practice Address - Street 1:12440 EAST NORWALK BOULEVARD
Practice Address - Street 2:SUITE 3020
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-9331
Practice Address - Country:US
Practice Address - Phone:562-864-7821
Practice Address - Fax:562-864-7864
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPT37762167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician