Provider Demographics
NPI:1255474557
Name:FLEMING, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:FLEMING
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 1:975 E GREEN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:975 E GREEN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2400
Practice Address - Country:US
Practice Address - Phone:818-952-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS54171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW054170Medicaid
CA2519432Medicare UPIN
SW5417Medicare ID - Type Unspecified