Healthcare Provider Details

I. General information

NPI: 1942947478
Provider Name (Legal Business Name): MIRANDA GREEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E 5TH ST STE 154
WASHINGTON MO
63090-3136
US

IV. Provider business mailing address

1717 GREEN LN
SAINT CLAIR MO
63077-3443
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6663
  • Fax:
Mailing address:
  • Phone: 636-584-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2020011992
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: