Provider Demographics
NPI:1972114759
Name:LOUIS, BRUCE A
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:LOUIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1704
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-9107
Mailing Address - Country:US
Mailing Address - Phone:360-485-6212
Mailing Address - Fax:804-451-9078
Practice Address - Street 1:15607 CHESDIN MANOR DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23838-4520
Practice Address - Country:US
Practice Address - Phone:360-485-6212
Practice Address - Fax:804-451-9078
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60809541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health