Provider Demographics
NPI:1790827400
Name:BRUECKNER, AMY ELIZABETH (MA,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:BRUECKNER
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 KNOX ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2012
Mailing Address - Country:US
Mailing Address - Phone:573-204-7861
Mailing Address - Fax:
Practice Address - Street 1:414 KNOX ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2012
Practice Address - Country:US
Practice Address - Phone:573-204-7861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005001727235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist