MEDICARE: MRS. MIRIAM AMANDA BRANHAM MS, CCC SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	17043	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	75-06582802	OTHER	TX	TAX ID NUMBER
2	528357	OTHER	TX	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1538177050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIRIAM AMANDA BRANHAM MS, CCC SLP

Provider Business Mailing Address
First Line	:	1629 W MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-4711
Country	:	US
Telephone Number	:	713-807-1131
Fax Number	:	713-807-1141

Provider Business Practice Location Address
First Line	:	1629 W MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77006-4711
Country	:	US
Telephone Number	:	713-807-1131
Fax Number	:	713-807-1141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	05/20/2022

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