Provider Demographics
NPI:1992882351
Name:NIEMITZ, BRUNO ANTHONY (LCSW, LMFT)
Entity type:Individual
Prefix:
First Name:BRUNO
Middle Name:ANTHONY
Last Name:NIEMITZ
Suffix:
Gender:M
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33393
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27636-3393
Mailing Address - Country:US
Mailing Address - Phone:919-821-0790
Mailing Address - Fax:919-861-8961
Practice Address - Street 1:3937 WESTERN BLVD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1936
Practice Address - Country:US
Practice Address - Phone:919-821-0790
Practice Address - Fax:919-861-8961
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0000641041C0700X
NC487106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC62601OtherBCBS PROVIDER NUMBER
NC6003333Medicaid
NC6003333Medicaid