Provider Demographics
NPI:1740357128
Name:BROMLEY, BRUCE LLOYD (PHD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:LLOYD
Last Name:BROMLEY
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 1:23619 PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-8551
Mailing Address - Country:US
Mailing Address - Phone:707-459-4309
Mailing Address - Fax:
Practice Address - Street 1:6300 E HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458
Practice Address - Country:US
Practice Address - Phone:707-274-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15244103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist