Provider Demographics
NPI:1205483609
Name:BRUCE, WESLEY C
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:C
Last Name:BRUCE
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 1:387 N 300 W
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-3547
Mailing Address - Country:US
Mailing Address - Phone:435-233-8504
Mailing Address - Fax:
Practice Address - Street 1:387 N 300 W
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-3547
Practice Address - Country:US
Practice Address - Phone:435-233-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11330856-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty