Provider Demographics
NPI:1730741265
Name:BRUDER, TIFFANY (PHD)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:BRUDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8207 FEATHERHILL RD APT 303
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9224
Mailing Address - Country:US
Mailing Address - Phone:347-392-0732
Mailing Address - Fax:
Practice Address - Street 1:10440 SHAKER DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1200
Practice Address - Country:US
Practice Address - Phone:347-392-0732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD06134OtherBOARD OF PSYCHOLOGY