Healthcare Provider Details

I. General information

NPI: 1497295562
Provider Name (Legal Business Name): BRUCE SKOVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 W MAIN AVE STE 100
DE PERE WI
54115-9556
US

IV. Provider business mailing address

PO BOX 13156
GREEN BAY WI
54307-3156
US

V. Phone/Fax

Practice location:
  • Phone: 920-403-7600
  • Fax: 920-403-7630
Mailing address:
  • Phone: 920-403-7600
  • Fax: 920-403-7630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: