Provider Demographics
NPI:1497889968
Name:BRANNON, MARILYN E (PHD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:E
Last Name:BRANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 TREJO STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-3776
Mailing Address - Fax:208-356-9498
Practice Address - Street 1:534 TREJO STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-3776
Practice Address - Fax:208-356-9498
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 229103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0010016770OtherREGENCE BLUE SHIELD OF ID
IDN2290OtherBLUE CROSS OF IDAHO
IDN2290OtherBLUE CROSS OF IDAHO