Provider Demographics
NPI:1124243076
Name:EBERT, BRUCE W (PHD, JD, LLM)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
Last Name:EBERT
Suffix:
Gender:M
Credentials:PHD, JD, LLM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:775 SUNRISE AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4523
Mailing Address - Country:US
Mailing Address - Phone:916-781-7875
Mailing Address - Fax:916-781-2632
Practice Address - Street 1:775 SUNRISE AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4523
Practice Address - Country:US
Practice Address - Phone:916-781-7875
Practice Address - Fax:916-781-2632
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7461103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic