Provider Demographics
NPI:1316242167
Name:BRUCE, RODERICK W (LCSW)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:W
Last Name:BRUCE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10765 LANTERN RD
Mailing Address - Street 2:STE 102
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-3596
Mailing Address - Country:US
Mailing Address - Phone:317-621-4181
Mailing Address - Fax:317-621-4182
Practice Address - Street 1:10765 LANTERN RD
Practice Address - Street 2:STE 102
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-3596
Practice Address - Country:US
Practice Address - Phone:317-621-4181
Practice Address - Fax:317-621-4182
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004707A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9709665OtherAETNA
IN000000701068OtherANTHEM
INM400039754Medicare PIN