Healthcare Provider Details

I. General information

NPI: 1033862008
Provider Name (Legal Business Name): MIRANDA BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA NICHOLSON

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 BAILEY AVE
BUFFALO NY
14215-2814
US

IV. Provider business mailing address

55 DODGE RD
GETZVILLE NY
14068-1205
US

V. Phone/Fax

Practice location:
  • Phone: 716-833-3622
  • Fax:
Mailing address:
  • Phone: 716-831-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017944
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: