Provider Demographics
NPI:1831483718
Name:BRUNER, AMANDA LYNN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:BRUNER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 E KENNEDY BLVD
Mailing Address - Street 2:UNIT #N447
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3545
Mailing Address - Country:US
Mailing Address - Phone:813-625-5774
Mailing Address - Fax:
Practice Address - Street 1:3850 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3670
Practice Address - Country:US
Practice Address - Phone:727-786-5482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11471235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist