Provider Demographics
NPI:1205582103
Name:BRUCE, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BRUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 VERDI BLVD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-3015
Mailing Address - Country:US
Mailing Address - Phone:518-813-0901
Mailing Address - Fax:
Practice Address - Street 1:32 COHOES RD
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:NY
Practice Address - Zip Code:12189-1811
Practice Address - Country:US
Practice Address - Phone:518-782-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1083541041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool