Provider Demographics
NPI:1285725424
Name:DOUGLASS, BRUCE G (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:G
Last Name:DOUGLASS
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 1:934 S GARFIELD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2402
Mailing Address - Country:US
Mailing Address - Phone:231-946-4419
Mailing Address - Fax:
Practice Address - Street 1:934 S GARFIELD AVE STE C
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2402
Practice Address - Country:US
Practice Address - Phone:231-946-4419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2009-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI003193103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383446966OtherTAX ID
MI680B813220OtherBCBS
MIS07411Medicare UPIN
MI680B813220OtherBCBS