Provider Demographics
NPI:1073167706
Name:GILL, MIRANDA (MS)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1118
Mailing Address - Country:US
Mailing Address - Phone:606-717-1024
Mailing Address - Fax:
Practice Address - Street 1:110 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1118
Practice Address - Country:US
Practice Address - Phone:606-717-1024
Practice Address - Fax:606-717-1048
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
KY106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid