Provider Demographics
NPI:1366562241
Name:CONN, A BRUCE (LMFT)
Entity type:Individual
Prefix:
First Name:A
Middle Name:BRUCE
Last Name:CONN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N CREST BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1845
Mailing Address - Country:US
Mailing Address - Phone:478-474-4265
Mailing Address - Fax:
Practice Address - Street 1:135 N CREST BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1845
Practice Address - Country:US
Practice Address - Phone:478-474-4265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT000774106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMFT000774OtherSTATE LICENSE