Provider Demographics
NPI:1477639540
Name:BIRD, MARILYN REID (MS)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:REID
Last Name:BIRD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 MILLICH DR STE 105
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0550
Mailing Address - Country:US
Mailing Address - Phone:408-379-0245
Mailing Address - Fax:408-379-0361
Practice Address - Street 1:595 MILLICH DR STE 105
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0550
Practice Address - Country:US
Practice Address - Phone:408-379-0245
Practice Address - Fax:408-379-0361
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP003087235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP003087OtherPRIVATE PRACTICE LICENSE