Provider Demographics
NPI:1215735949
Name:AUTRY, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:AUTRY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13921 YUKON AVE APT 108
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8125
Mailing Address - Country:US
Mailing Address - Phone:424-207-6829
Mailing Address - Fax:
Practice Address - Street 1:13921 YUKON AVE APT 108
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8125
Practice Address - Country:US
Practice Address - Phone:424-207-6829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst