Individual
MANZA BLAINE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
310 AUTUMN RIDGE DR, KOSCIUSKO, MS 39090-3242
(601) 250-4815
Mailing address
202 GALLOWAY DR, KOSCIUSKO, MS 39090-3920
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
S2770
MS
Other
Enumeration date
09/16/2008
Last updated
09/30/2008
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