Healthcare Provider Details

I. General information

NPI: 1992497754
Provider Name (Legal Business Name): MIRANDA WARD LMFT, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 OTTAWA AVE NW STE 405
GRAND RAPIDS MI
49503-2648
US

IV. Provider business mailing address

80 OTTAWA AVE NW
GRAND RAPIDS MI
49503-6205
US

V. Phone/Fax

Practice location:
  • Phone: 616-209-8645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451022945
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4151001098
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101007462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: