Provider Demographics
NPI:1093116725
Name:BRUCH, HOLLY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BRUCH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 SHIELD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2148
Mailing Address - Country:US
Mailing Address - Phone:307-742-3571
Mailing Address - Fax:307-742-6397
Practice Address - Street 1:715 SHIELD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2148
Practice Address - Country:US
Practice Address - Phone:307-742-3571
Practice Address - Fax:307-742-6397
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-533235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist