Provider Demographics
NPI:1205891561
Name:ROTTSCHAFER, BRUCE (PHD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:ROTTSCHAFER
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 1:2501 E PIEDMONT RD
Mailing Address - Street 2:SUITE 147
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7752
Mailing Address - Country:US
Mailing Address - Phone:770-977-9201
Mailing Address - Fax:770-947-5650
Practice Address - Street 1:2501 E PIEDMONT RD
Practice Address - Street 2:SUITE 147
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7752
Practice Address - Country:US
Practice Address - Phone:770-977-9201
Practice Address - Fax:770-947-5650
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002212103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBFKVMedicare PIN