Provider Demographics
NPI:1245269844
Name:BRUCE, JAMES RUSSELL (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RUSSELL
Last Name:BRUCE
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 1:1120 N GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2310
Mailing Address - Country:US
Mailing Address - Phone:208-345-1414
Mailing Address - Fax:208-345-4010
Practice Address - Street 1:1120 N GARDEN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2310
Practice Address - Country:US
Practice Address - Phone:208-345-1414
Practice Address - Fax:208-345-4010
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY181103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1550323Medicare ID - Type Unspecified
ID1684356Medicare ID - Type Unspecified