Provider Demographics
NPI:1871952978
Name:ATHERTON, BRUCE DWAIN (JD)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DWAIN
Last Name:ATHERTON
Suffix:
Gender:M
Credentials:JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 DUTCHMANS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4704
Mailing Address - Country:US
Mailing Address - Phone:502-424-4452
Mailing Address - Fax:502-896-8607
Practice Address - Street 1:4006 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4704
Practice Address - Country:US
Practice Address - Phone:502-424-4452
Practice Address - Fax:502-896-8607
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81045103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst