Healthcare Provider Details

I. General information

NPI: 1114977253
Provider Name (Legal Business Name): SUE MIRANDY LEDERER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 HIGH ST
GREENFIELD MA
01301-2973
US

IV. Provider business mailing address

PO BOX 752
GREENFIELD MA
01302-0752
US

V. Phone/Fax

Practice location:
  • Phone: 413-773-1966
  • Fax:
Mailing address:
  • Phone: 413-773-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089-0000688
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1015428
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: