Healthcare Provider Details

I. General information

NPI: 1801301858
Provider Name (Legal Business Name): MIRANDA KIMBERLY WADLEY LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23215 COMMERCE PARK
CLEVELAND OH
44122
US

IV. Provider business mailing address

23840 PURITAN RD
EUCLID OH
44123-2246
US

V. Phone/Fax

Practice location:
  • Phone: 216-224-7331
  • Fax:
Mailing address:
  • Phone: 216-224-7331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1801112
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0031105
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: