Provider Demographics
NPI:1811917875
Name:MINDRUP, BRUCE PATTON (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:PATTON
Last Name:MINDRUP
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 1:106 GOODRICH ST
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2212
Mailing Address - Country:US
Mailing Address - Phone:618-498-4911
Mailing Address - Fax:618-498-4921
Practice Address - Street 1:106 GOODRICH ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2212
Practice Address - Country:US
Practice Address - Phone:618-498-4911
Practice Address - Fax:618-498-4921
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health