Healthcare Provider Details

I. General information

NPI: 1336521236
Provider Name (Legal Business Name): MIRANDA GROEBLER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 6TH ST
MALONE NY
12953-1246
US

IV. Provider business mailing address

4 COMMERCE LN
CANTON NY
13617-3739
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-3261
  • Fax: 518-483-3383
Mailing address:
  • Phone: 315-386-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number401866
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: