Provider Demographics
NPI:1457655631
Name:LABRUM, MANDARAN
Entity Type:Individual
Prefix:
First Name:MANDARAN
Middle Name:
Last Name:LABRUM
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 1:2055 GARRETT WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5155
Mailing Address - Country:US
Mailing Address - Phone:208-233-7832
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:2055 GARRETT WAY STE 1
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5155
Practice Address - Country:US
Practice Address - Phone:208-233-7832
Practice Address - Fax:208-236-6695
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health