Provider Demographics
NPI:1073127874
Name:KOGON, MIRANDA B (BCBA, DBH)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:B
Last Name:KOGON
Suffix:
Gender:F
Credentials:BCBA, DBH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 UNIVERSITY BLVD W APT 608
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-1834
Mailing Address - Country:US
Mailing Address - Phone:845-546-4216
Mailing Address - Fax:
Practice Address - Street 1:3333 UNIVERSITY BLVD W APT 608
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-1834
Practice Address - Country:US
Practice Address - Phone:845-546-4216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-42871103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD103K00000XMedicaid