Provider Demographics
NPI:1629341219
Name:PERSON, BRUCE (LCSW)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:PERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 E GATE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6137
Mailing Address - Country:US
Mailing Address - Phone:815-986-1113
Mailing Address - Fax:815-986-1119
Practice Address - Street 1:1752 WINDSOR RD STE 203
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4276
Practice Address - Country:US
Practice Address - Phone:815-986-1113
Practice Address - Fax:815-986-1119
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0075481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-007548OtherSTATE OF ILLINOIS LICENSE