Provider Demographics
NPI:1922057694
Name:MCNICKLE, BRUCE C (PHD LP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:C
Last Name:MCNICKLE
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-656-7026
Practice Address - Street 1:1900 CENTRACARE CIRCLE
Practice Address - Street 2:CENTRACARE HEALTH PLAZA
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-229-4977
Practice Address - Fax:320-656-7058
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1975103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling