Healthcare Provider Details

I. General information

NPI: 1356973614
Provider Name (Legal Business Name): MIRANDA AMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 THISTLE LN
DAVIS WV
26260-1104
US

IV. Provider business mailing address

25 THISTLE LN
DAVIS WV
26260-1104
US

V. Phone/Fax

Practice location:
  • Phone: 304-801-3258
  • Fax: 304-362-0025
Mailing address:
  • Phone: 304-801-3258
  • Fax: 304-362-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: