Provider Demographics
NPI:1790428027
Name:BRUGGEMAN, AUDREY ALEXA
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ALEXA
Last Name:BRUGGEMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:ALEXA
Other - Last Name:SANDOVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13481 W MCDOWELL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2724
Mailing Address - Country:US
Mailing Address - Phone:623-536-2325
Mailing Address - Fax:623-536-2056
Practice Address - Street 1:13481 W MCDOWELL RD STE 300
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2724
Practice Address - Country:US
Practice Address - Phone:623-536-2325
Practice Address - Fax:623-536-2056
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA135902355S0801X
AZSLP16043235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLPA13590Medicaid