Provider Demographics
NPI:1063187847
Name:THORSRUD, BRIANNA (CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:THORSRUD
Suffix:
Gender:F
Credentials:CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8641 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1788
Mailing Address - Country:US
Mailing Address - Phone:734-231-1694
Mailing Address - Fax:
Practice Address - Street 1:19697 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1119
Practice Address - Country:US
Practice Address - Phone:734-857-7896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000298235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist