Healthcare Provider Details

I. General information

NPI: 1932224052
Provider Name (Legal Business Name): JAMES CHARLES BRUCE JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 BURLINGTON AVE
WESTERN SPRINGS IL
60558-1516
US

IV. Provider business mailing address

1109 WESLEY AVE
OAK PARK IL
60304-2021
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-0826
  • Fax: 708-354-0867
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071004983
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: