Provider Demographics
NPI:1053086827
Name:OWEN, MIRANDA LINDSAY
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LINDSAY
Last Name:OWEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:LINDSAY
Other - Last Name:JOLLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 E PIONEER
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3265
Mailing Address - Country:US
Mailing Address - Phone:253-697-8400
Mailing Address - Fax:
Practice Address - Street 1:312 4TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3269
Practice Address - Country:US
Practice Address - Phone:253-697-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor