Healthcare Provider Details

I. General information

NPI: 1356681308
Provider Name (Legal Business Name): MIRANDA MARIE FASSBENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 DERONDA ST
AMERY WI
54001-1412
US

IV. Provider business mailing address

2265 COMO AVE
SAINT PAUL MN
55108-1737
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8000
  • Fax:
Mailing address:
  • Phone: 651-645-5323
  • Fax: 651-379-6141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1887
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5640.125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: