Provider Demographics
NPI:1205921061
Name:LADLE, BRUCE L (PHD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:LADLE
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 1:30 E APPLE ST
Mailing Address - Street 2:SUITE 6255
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-4452
Mailing Address - Fax:937-208-3893
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:SUITE 6255
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-4452
Practice Address - Fax:937-208-3893
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4850103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0981497Medicaid
OH5935608Medicaid
ND31053750400OtherBWC PSYCHOLOGIST
OHCP15495Medicare PIN