Provider Demographics
NPI:1164153318
Name:GERTLAR, ELIZA MINCULESCU
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:MINCULESCU
Last Name:GERTLAR
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 1:1043 W PARKSTONE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6031
Mailing Address - Country:US
Mailing Address - Phone:503-701-5272
Mailing Address - Fax:
Practice Address - Street 1:5850 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5466
Practice Address - Country:US
Practice Address - Phone:208-544-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist