Provider Demographics
NPI:1750414546
Name:BRUNET, MITZI R (MS,CCC,SLP)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:R
Last Name:BRUNET
Suffix:
Gender:F
Credentials:MS,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:PO BOX 466
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-0466
Mailing Address - Country:US
Mailing Address - Phone:985-632-4763
Mailing Address - Fax:
Practice Address - Street 1:106 WEST 164 STREET
Practice Address - Street 2:
Practice Address - City:GALLIANO
Practice Address - State:LA
Practice Address - Zip Code:70354
Practice Address - Country:US
Practice Address - Phone:985-632-4763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1472352Medicaid