MEDICARE: WILLIAM BRUINSMA PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2004152	IN

General Provider Information

NPI Number	:	1598145484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM BRUINSMA PSYD

Provider Business Mailing Address
First Line	:	2560 BUSINESS PKWY
Second Line	:	SUITE A
City	:	MINDEN
State	:	NV
Zip	:	89423-8985
Country	:	US
Telephone Number	:	574-339-4419
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 S MICHIGAN ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-3426
Country	:	US
Telephone Number	:	574-339-4419
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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