Provider Demographics
NPI:1710304720
Name:BROWNE, DIETRICH MARK (MA,CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:DIETRICH
Middle Name:MARK
Last Name:BROWNE
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Gender:M
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1301 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5390
Mailing Address - Country:US
Mailing Address - Phone:321-421-6992
Mailing Address - Fax:321-421-6993
Practice Address - Street 1:1301 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5390
Practice Address - Country:US
Practice Address - Phone:321-421-6992
Practice Address - Fax:321-421-6993
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLSA12818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist