Provider Demographics
NPI:1528301157
Name:OSBORN, BRUCE EUGENE
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EUGENE
Last Name:OSBORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 NARANCA AVE APT B
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-7409
Mailing Address - Country:US
Mailing Address - Phone:619-401-9436
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY STE 407
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5714
Practice Address - Country:US
Practice Address - Phone:760-758-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA90094106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program