Healthcare Provider Details

I. General information

NPI: 1366430746
Provider Name (Legal Business Name): BRUCE FISCHER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 SNOWBERRY DR
LONGS SC
29568-8120
US

IV. Provider business mailing address

1026 SNOWBERRY DR
LONGS SC
29568-8120
US

V. Phone/Fax

Practice location:
  • Phone: 631-946-1249
  • Fax:
Mailing address:
  • Phone: 631-946-1249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1049
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: