Healthcare Provider Details

I. General information

NPI: 1821127234
Provider Name (Legal Business Name): SHANE BRUCE L.M.F.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 04/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 SANTA YNEZ AVE
CARPINTERIA CA
93013-1311
US

IV. Provider business mailing address

30 W MISSION ST STE 5
SANTA BARBARA CA
93101-0401
US

V. Phone/Fax

Practice location:
  • Phone: 323-610-5802
  • Fax:
Mailing address:
  • Phone: 323-285-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 50773
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: