Provider Demographics
NPI:1437431608
Name:BRUCKMAN, STEPHANIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:BRUCKMAN
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 1:1 BERNABI RD
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1800
Mailing Address - Country:US
Mailing Address - Phone:585-349-5455
Mailing Address - Fax:
Practice Address - Street 1:1 BERNABI RD
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1800
Practice Address - Country:US
Practice Address - Phone:585-349-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021391-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021391-1Medicaid