Provider Demographics
NPI:1912215443
Name:OTTENBREIT, BRUCE DENNIS (LMSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DENNIS
Last Name:OTTENBREIT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15350 N COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1297
Mailing Address - Country:US
Mailing Address - Phone:313-575-6297
Mailing Address - Fax:313-406-6433
Practice Address - Street 1:15350 N COMMERCE DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1297
Practice Address - Country:US
Practice Address - Phone:313-575-6297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010076031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical