Provider Demographics
NPI:1750718821
Name:FRY, BRUCE HOWARD (CADC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:HOWARD
Last Name:FRY
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13213 VISCHER RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9025
Mailing Address - Country:US
Mailing Address - Phone:517-260-2015
Mailing Address - Fax:
Practice Address - Street 1:199 N BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2762
Practice Address - Country:US
Practice Address - Phone:517-263-2191
Practice Address - Fax:517-264-6080
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01434101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)