Provider Demographics
NPI:1700163359
Name:MILBRANDT, MARIETTE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARIETTE
Middle Name:
Last Name:MILBRANDT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8116
Mailing Address - Country:US
Mailing Address - Phone:208-282-3495
Mailing Address - Fax:
Practice Address - Street 1:650 MEMORIAL DRIVE
Practice Address - Street 2:BUILDING #68
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-282-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1688235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist