MEDICARE: DR. JUDY CONOYER BRONSON PH.D.

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	103T00000X	Psychologist	2006029947	MO

General Provider Information

NPI Number	:	1124176623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUDY CONOYER BRONSON PH.D.

Provider Business Mailing Address
First Line	:	119 CLARKSON EXECUTIVE PARK
Second Line	:
City	:	ELLISVILLE
State	:	MO
Zip	:	63011-2044
Country	:	US
Telephone Number	:	636-256-0600
Fax Number	:	636-256-0626

Provider Business Practice Location Address
First Line	:	119 CLARKSON EXECUTIVE PARK
Second Line	:
City	:	ELLISVILLE
State	:	MO
Zip	:	63011-2044
Country	:	US
Telephone Number	:	636-256-0600
Fax Number	:	636-256-0626

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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