MEDICARE: MIRANDA PITONAK MA, LPC, CRC

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	101YP2500X	Professional Counselor	2017039074	MO

General Provider Information

NPI Number	:	1487276127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA PITONAK MA, LPC, CRC

Provider Business Mailing Address
First Line	:	659 BEATRICE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-3235
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	659 BEATRICE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-3235
Country	:	US
Telephone Number	:	314-740-8449
Fax Number	:

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

Provider Enumeration Date	:	05/16/2020
Last Update Date	:	07/06/2020

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