Provider Demographics
NPI:1922582014
Name:BRUNER, DEMETRI ANTONI (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEMETRI
Middle Name:ANTONI
Last Name:BRUNER
Suffix:
Gender:M
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:CARAWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72419-9027
Mailing Address - Country:US
Mailing Address - Phone:870-371-1809
Mailing Address - Fax:
Practice Address - Street 1:1699 RED WOLF BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5442
Practice Address - Country:US
Practice Address - Phone:870-336-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist