Provider Demographics
NPI:1164591046
Name:MAHLUM, BRENDA (PT)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:MAHLUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 CAMPUS DRIVE
Mailing Address - Street 2:PMB 1217
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4492
Mailing Address - Country:US
Mailing Address - Phone:406-370-1377
Mailing Address - Fax:800-886-0200
Practice Address - Street 1:945 WYOMING ST UNIT 135
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2057
Practice Address - Country:US
Practice Address - Phone:406-544-6090
Practice Address - Fax:800-886-0200
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPT432225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1164591046Medicaid