Healthcare Provider Details

I. General information

NPI: 1598039992
Provider Name (Legal Business Name): BRUCE RAY BREWER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 WEST FIRECLAY AVE SUITE C-105
MURRY UT
84107-2637
US

IV. Provider business mailing address

3823 PEBBLE LN
PROVO UT
84604-5268
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-1499
  • Fax:
Mailing address:
  • Phone: 801-371-0388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number319691-2504
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: