Provider Demographics
NPI:1174234140
Name:CERBONE, BRUCE J (MA, BCPC, CCTP)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:CERBONE
Suffix:
Gender:M
Credentials:MA, BCPC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 RIDENOUR BLVD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4528
Mailing Address - Country:US
Mailing Address - Phone:770-335-9521
Mailing Address - Fax:
Practice Address - Street 1:1300 RIDENOUR BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4528
Practice Address - Country:US
Practice Address - Phone:770-335-9521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062222526101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral