Healthcare Provider Details

I. General information

NPI: 1689027260
Provider Name (Legal Business Name): MIRANDA PRATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 W MAIN ST
PLAINVILLE CT
06062
US

IV. Provider business mailing address

56 W MAIN ST
PLAINVILLE CT
06062-1904
US

V. Phone/Fax

Practice location:
  • Phone: 860-351-5407
  • Fax: 860-351-5774
Mailing address:
  • Phone: 860-351-5407
  • Fax: 860-351-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA.000868
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: