Provider Demographics
NPI:1740480755
Name:MALCOLM, BRUCE EDWARD (PSYD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 KEVIN CT NE
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-9446
Mailing Address - Country:US
Mailing Address - Phone:330-401-5244
Mailing Address - Fax:
Practice Address - Street 1:3593 MEDINA RD # 181
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8182
Practice Address - Country:US
Practice Address - Phone:330-401-5244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7105103TC0700X
MI6301012060103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H215160OtherBC/BS OF MICHIGAN
MI3218695674OtherPPOM
MI382695674OtherVALUE OPTIONS
MI371354712OtherMAGELLAN
MI680H215160OtherBC/BS OF MICHIGAN