Provider Demographics
NPI:1598039992
Name:BREWER, BRUCE RAY (PHD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RAY
Last Name:BREWER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 PEBBLE LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5268
Mailing Address - Country:US
Mailing Address - Phone:801-371-0388
Mailing Address - Fax:
Practice Address - Street 1:22 WEST FIRECLAY AVE
Practice Address - Street 2:SUITE C-105
Practice Address - City:MURRY
Practice Address - State:UT
Practice Address - Zip Code:84107-2637
Practice Address - Country:US
Practice Address - Phone:801-266-1499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT319691-2504103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical