Provider Demographics
NPI:1942426010
Name:GREGORY, BRUCE (PHD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15235 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3500
Mailing Address - Country:US
Mailing Address - Phone:818-781-3098
Mailing Address - Fax:310-456-1053
Practice Address - Street 1:15235 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-3500
Practice Address - Country:US
Practice Address - Phone:818-781-3098
Practice Address - Fax:310-456-1053
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 6497106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist