Provider Demographics
NPI:1104339134
Name:BRUCE, MARY (LCDCIII)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MARION PIKE
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2960
Mailing Address - Country:US
Mailing Address - Phone:740-377-1998
Mailing Address - Fax:
Practice Address - Street 1:425 MARION PIKE
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2960
Practice Address - Country:US
Practice Address - Phone:740-377-1998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161421101YA0400X
171M00000X
LCDCIII.161773101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator