Provider Demographics
NPI:1518377464
Name:BRUCE, LARA S (MA, SLP)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:S
Last Name:BRUCE
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S BRAINARD ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-4901
Mailing Address - Country:US
Mailing Address - Phone:630-637-9937
Mailing Address - Fax:
Practice Address - Street 1:15 S BRAINARD ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-4901
Practice Address - Country:US
Practice Address - Phone:630-637-9937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005257235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist