MEDICARE: MS. MARY JO STARCK BRUCKNER MS, CCC-SP

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	:	1356679054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY JO STARCK BRUCKNER MS, CCC-SP

Provider Business Mailing Address
First Line	:	4909 E MERCER WAY
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-4737
Country	:	US
Telephone Number	:	206-484-7723
Fax Number	:

Provider Business Practice Location Address
First Line	:	4909 E MERCER WAY
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-4737
Country	:	US
Telephone Number	:	206-484-7723
Fax Number	:

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

Provider Enumeration Date	:	11/18/2009
Last Update Date	:	11/18/2009

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