Healthcare Provider Details

I. General information

NPI: 1396709341
Provider Name (Legal Business Name): BRUCE EADS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NAVAHO DR SUITE 123
RALEIGH NC
27609-7319
US

IV. Provider business mailing address

2359 DERBY DR
RALEIGH NC
27610-1741
US

V. Phone/Fax

Practice location:
  • Phone: 919-412-7069
  • Fax: 919-832-4708
Mailing address:
  • Phone: 919-412-7069
  • Fax: 919-832-4708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004096
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: