=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518392489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRANDA ANN SUMNER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2013
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1524 FREDERICA ST
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42301-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-925-6058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5141 PLEASANT VALLEY RD
-----------------------------------------------------
City | PHILPOT
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42366-9754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-925-6058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 252696
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------