Healthcare Provider Details

I. General information

NPI: 1710052618
Provider Name (Legal Business Name): MIRANDA RAE FANI SROUR LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA RAE MYERS MSW

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 SAGAMORE AVE
PORTSMOUTH NH
03801-5585
US

IV. Provider business mailing address

4 MERRY MEETING LN
RYE NH
03870-2325
US

V. Phone/Fax

Practice location:
  • Phone: 603-431-6703
  • Fax: 603-430-3753
Mailing address:
  • Phone: 617-504-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115136
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: