Individual
MR. BRUCE BLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSYCH TECH
Contact information
Practice address
2225 CHALLENGER WAY, SANTA ROSA, CA 95407
(707) 576-8181
Mailing address
2225 CHALLENGER WAY, SANTA ROSA, CA 95407-5441
(707) 576-8181
Taxonomy
Speciality
Code
Description
License number
State
167G00000X
Licensed Psychiatric Technician
Primary
PT 31504
CA
Other
Enumeration date
10/19/2016
Last updated
10/19/2016
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