Healthcare Provider Details

I. General information

NPI: 1407451164
Provider Name (Legal Business Name): ALAN W BRUE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 FELTON PL STE A
CARTERSVILLE GA
30120-2153
US

IV. Provider business mailing address

17 FELTON PL STE A
CARTERSVILLE GA
30120-2153
US

V. Phone/Fax

Practice location:
  • Phone: 770-386-8996
  • Fax: 770-386-8100
Mailing address:
  • Phone: 770-386-8996
  • Fax: 770-386-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY004429
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: