Provider Demographics
NPI:1700958303
Name:BRUCE, VICTORIA SUZANNE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:SUZANNE
Last Name:BRUCE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:VICTORIA
Other - Middle Name:SUZANNE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:2104 WINSBURG DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5227
Mailing Address - Country:US
Mailing Address - Phone:770-418-1778
Mailing Address - Fax:
Practice Address - Street 1:3483 SATELLITE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8692
Practice Address - Country:US
Practice Address - Phone:770-418-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004367171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor