Healthcare Provider Details

I. General information

NPI: 1073010112
Provider Name (Legal Business Name): MIRANDA ELIZABETH THISSEN BCBA, COBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E DUBLIN GRANVILLE RD
WORTHINGTON OH
43085-3192
US

IV. Provider business mailing address

22 N 1ST ST
NEWARK OH
43055-5608
US

V. Phone/Fax

Practice location:
  • Phone: 614-436-7837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-69933
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: