Provider Demographics
NPI:1669763306
Name:BRUCE, TINA (LPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SERGEANT PRENTISS DR
Mailing Address - Street 2:STE 102
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4791
Mailing Address - Country:US
Mailing Address - Phone:601-653-4581
Mailing Address - Fax:
Practice Address - Street 1:6300 RIDGLEA PL STE 425-B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5704
Practice Address - Country:US
Practice Address - Phone:682-224-7500
Practice Address - Fax:682-224-7501
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5910101YM0800X
TX83432101YM0800X
251B00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management