Provider Demographics
NPI:1801940689
Name:JOHNSTON, BRUCE BOWER (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BOWER
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:26000 AVENIDA AEROPUERTO
Mailing Address - Street 2:#216
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4720
Mailing Address - Country:US
Mailing Address - Phone:949-224-9072
Mailing Address - Fax:949-429-8723
Practice Address - Street 1:30100 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 17
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2041
Practice Address - Country:US
Practice Address - Phone:949-224-9072
Practice Address - Fax:949-429-8723
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954586Medicare UPIN
CACP14156BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER