Basic Information
| Provider Information | |||||||||
| NPI: | 1700187267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCKS | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | RENEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1102 W 32ND ST | ||||||||
| Address2: | FREEMAN OUTPATIENT REHABILITATION | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043503 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1102 W 32ND ST | ||||||||
| Address2: | FREEMAN OUTPATIENT REHABILITATION | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173471111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2010 | ||||||||
| LastUpdateDate: | 11/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2010036789 | MO | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.