Provider Demographics
NPI:1720840374
Name:BRUDVIG, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BRUDVIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 S GRAND SLAM PL APT 7
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-4819
Mailing Address - Country:US
Mailing Address - Phone:605-610-5590
Mailing Address - Fax:
Practice Address - Street 1:100 N HOWARD ST STE W
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0508
Practice Address - Country:US
Practice Address - Phone:206-504-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health