Provider Demographics
NPI:1891040903
Name:WEATHERLY, BRUCE (PSY)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WEATHERLY
Suffix:
Gender:M
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1777
Mailing Address - Country:US
Mailing Address - Phone:814-876-2938
Mailing Address - Fax:410-569-0094
Practice Address - Street 1:5630 DEVONSHIRE RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-3911
Practice Address - Country:US
Practice Address - Phone:814-876-2938
Practice Address - Fax:410-569-0094
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-005590-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist