Provider Demographics
NPI:1730788811
Name:BRERETON, TRUDY ROSE
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:ROSE
Last Name:BRERETON
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 1:55 S 500 E
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-1918
Mailing Address - Country:US
Mailing Address - Phone:435-654-3303
Mailing Address - Fax:
Practice Address - Street 1:55 S 500 E
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1918
Practice Address - Country:US
Practice Address - Phone:435-654-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator