Healthcare Provider Details

I. General information

NPI: 1699603928
Provider Name (Legal Business Name): MIRANDA ANDERSON LAPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 ALABAMA AVE S
BREMEN GA
30110-2501
US

IV. Provider business mailing address

605 LEGION LAKE RD
VILLA RICA GA
30180-5070
US

V. Phone/Fax

Practice location:
  • Phone: 678-446-0883
  • Fax: 770-537-7003
Mailing address:
  • Phone: 678-446-0883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC009917
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: