Provider Demographics
NPI:1194230946
Name:BRUE, STORMI (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STORMI
Middle Name:
Last Name:BRUE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:STORMI
Other - Middle Name:
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:842 RED BUD PL
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62675-9576
Mailing Address - Country:US
Mailing Address - Phone:217-899-6829
Mailing Address - Fax:
Practice Address - Street 1:842 RED BUD PL
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675-9576
Practice Address - Country:US
Practice Address - Phone:217-899-6829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146014291235Z00000X
IL242004556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist