Healthcare Provider Details

I. General information

NPI: 1487560728
Provider Name (Legal Business Name): MIRANDA GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S 9TH ST
CANON CITY CO
81212-3800
US

IV. Provider business mailing address

127 D ST MAILBOX 1/4
SALIDA CO
81201-2838
US

V. Phone/Fax

Practice location:
  • Phone: 719-430-5292
  • Fax:
Mailing address:
  • Phone: 206-914-4937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: