MEDICARE: MS. ANDRA MARIE BRUCE LCSW

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	1041C0700X	Clinical Social Worker	357058-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	751647	OTHER	UT	DESERET MUTUAL
2	107012409101	OTHER	UT	INTERMOUNTAIN HEALTH CARE
3	942938348BRU	OTHER	UT	EDUCATORS MUTUAL

General Provider Information

NPI Number	:	1396723334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANDRA MARIE BRUCE LCSW

Provider Business Mailing Address
First Line	:	4460 S HIGHLAND DR
Second Line	:	STE 230
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3543
Country	:	US
Telephone Number	:	888-949-4864
Fax Number	:

Provider Business Practice Location Address
First Line	:	4460 S HIGHLAND DR
Second Line	:	STE 230
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3543
Country	:	US
Telephone Number	:	888-949-4864
Fax Number	:

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

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	07/29/2016

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