Healthcare Provider Details

I. General information

NPI: 1609530948
Provider Name (Legal Business Name): MIRANDA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2133 3RD AVE
SEATTLE WA
98121-2385
US

IV. Provider business mailing address

12311 32ND AVE NE APT 624
SEATTLE WA
98125-5699
US

V. Phone/Fax

Practice location:
  • Phone: 206-432-3574
  • Fax:
Mailing address:
  • Phone: 206-403-3434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: