Healthcare Provider Details

I. General information

NPI: 1659513208
Provider Name (Legal Business Name): BRUCE G DOUGLASS PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2009
Last Update Date: 02/27/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5088 VILLAGE LANE CT
TRAVERSE CITY MI
49685-6924
US

IV. Provider business mailing address

5088 VILLAGE LANE CT
TRAVERSE CITY MI
49685-6924
US

V. Phone/Fax

Practice location:
  • Phone: 231-342-5877
  • Fax: 231-943-2108
Mailing address:
  • Phone: 231-342-5877
  • Fax: 231-943-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number6301003193
License Number StateMI

VIII. Authorized Official

Name: DR. BRUCE G DOUGLASS
Title or Position: MANAGER
Credential: PHD
Phone: 231-342-5877