Provider Demographics
NPI:1659997138
Name:BANKS, BRIANNE R (SLP)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:R
Last Name:BANKS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 GLENEAGLES DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6301
Mailing Address - Country:US
Mailing Address - Phone:208-709-2905
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5293
Practice Address - Country:US
Practice Address - Phone:208-356-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist