Active NPI
Bruce G Douglass, PHD
- Psychologist
- Traverse City, MI
National Provider Identifier
1285725424
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 003193
- Practice address
- 934 S Garfield Ave Ste C
Traverse City, MI 49686-2402 - Phone
- (231) 946-4419
- NPI assigned
- Sep 27, 2006
- Last updated
- Mar 28, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 003193 | MI | Primary |
Addresses
Primary practice location
934 S Garfield Ave Ste C
Traverse City, MI 49686-2402
Mailing address
934 S Garfield Ave Ste C
Traverse City, MI 49686-2402
Phone (231) 946-4419
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 383446966 | Other | MI | TAX ID |
| 680B813220 | Other | MI | BCBS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 003193 | MI | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159315200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1238198400000",
"number": "1285725424",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "934 S GARFIELD AVE STE C",
"city": "TRAVERSE CITY",
"state": "MI",
"postal_code": "496862402",
"telephone_number": "231-946-4419"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "934 S GARFIELD AVE STE C",
"city": "TRAVERSE CITY",
"state": "MI",
"postal_code": "496862402",
"telephone_number": "231-946-4419"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DOUGLASS",
"first_name": "BRUCE",
"middle_name": "G",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-09-27",
"last_updated": "2009-03-28",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MI",
"license": "003193",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TAX ID",
"identifier": "383446966",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "680B813220",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Traverse City, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 28, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.