Healthcare Provider Details

I. General information

NPI: 1740911379
Provider Name (Legal Business Name): MIRANDA MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA BROUK

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E OSAGE RD STE 300
DERBY KS
67037-2290
US

IV. Provider business mailing address

1721 E OSAGE RD STE 100
DERBY KS
67037-2198
US

V. Phone/Fax

Practice location:
  • Phone: 316-247-3161
  • Fax:
Mailing address:
  • Phone: 316-247-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04061
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: