Provider Demographics
NPI:1760635007
Name:BRUNDAGE, RIVER LOUISE (MSED,CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:RIVER
Middle Name:LOUISE
Last Name:BRUNDAGE
Suffix:
Gender:F
Credentials:MSED,CCC-SLP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:LOUISE
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED,CCC-SLP
Mailing Address - Street 1:9 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1235
Mailing Address - Country:US
Mailing Address - Phone:607-622-6092
Mailing Address - Fax:
Practice Address - Street 1:9 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1235
Practice Address - Country:US
Practice Address - Phone:607-622-6092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009955235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist