Provider Demographics
NPI:1538966536
Name:BRUCE, MATTHEW DAVID (LSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:BRUCE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 W RUDISILL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2142
Mailing Address - Country:US
Mailing Address - Phone:260-415-8428
Mailing Address - Fax:
Practice Address - Street 1:6339 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1547
Practice Address - Country:US
Practice Address - Phone:260-415-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33012842A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker