Provider Demographics
NPI:1679302897
Name:BRUCE, MALETA ANDREA (LMBT)
Entity type:Individual
Prefix:MRS
First Name:MALETA
Middle Name:ANDREA
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8807 KIRCHENBAUM DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-7657
Mailing Address - Country:US
Mailing Address - Phone:704-712-0413
Mailing Address - Fax:
Practice Address - Street 1:1200 E MOREHEAD ST STE 20Q
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2872
Practice Address - Country:US
Practice Address - Phone:704-712-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-27
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13583225700000X
NC21419225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist