Healthcare Provider Details

I. General information

NPI: 1073161667
Provider Name (Legal Business Name): MIRANDA NICOLE SHUMATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N BROADWAY
DENVER CO
80205-2526
US

IV. Provider business mailing address

2111 CHAMPA ST
DENVER CO
80205-2529
US

V. Phone/Fax

Practice location:
  • Phone: 303-293-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.020460
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09926723
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: