MEDICARE: DR. BRUCE CHESSEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	PY60894790	WA
2	103T00000X	Psychologist	MT147	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598799645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE CHESSEN PH.D.

Provider Business Mailing Address
First Line	:	3355 SHORELINE DR
Second Line	:
City	:	CAMANO ISLAND
State	:	WA
Zip	:	98282-8223
Country	:	US
Telephone Number	:	406-248-1126
Fax Number	:	406-245-0948

Provider Business Practice Location Address
First Line	:	3355 SHORELINE DR
Second Line	:
City	:	CAMANO ISLAND
State	:	WA
Zip	:	98282-8223
Country	:	US
Telephone Number	:	406-248-1126
Fax Number	:	406-245-0948

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	06/18/2021

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