Healthcare Provider Details

I. General information

NPI: 1972360410
Provider Name (Legal Business Name): MIRANDA HURLEBAUS MA, AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 VENTURA BLVD STE 210
ENCINO CA
91316-4153
US

IV. Provider business mailing address

5256 NOBLE AVE
SHERMAN OAKS CA
91411-3906
US

V. Phone/Fax

Practice location:
  • Phone: 818-570-1805
  • Fax:
Mailing address:
  • Phone: 507-398-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number145368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: