MEDICARE: RENEE BRUDER CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1295471886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE BRUDER CCC-SLP

Provider Business Mailing Address
First Line	:	824 S 400 W UNIT B321
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-4801
Country	:	US
Telephone Number	:	801-214-5991
Fax Number	:

Provider Business Practice Location Address
First Line	:	824 S 400 W UNIT B321
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-4801
Country	:	US
Telephone Number	:	801-214-5991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2022
Last Update Date	:	05/24/2022

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Directions to “ RENEE BRUDER CCC-SLP” Practice Location

Language	Start Address	Practice Location

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