Healthcare Provider Details

I. General information

NPI: 1134894983
Provider Name (Legal Business Name): MIRANDA MARIE KOBER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TERRADYNE DR STE 209
ANDOVER KS
67002-7941
US

IV. Provider business mailing address

PO BOX 354
GODDARD KS
67052-0354
US

V. Phone/Fax

Practice location:
  • Phone: 316-730-3647
  • Fax:
Mailing address:
  • Phone: 316-730-3647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number03291-T
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: