Provider Demographics
NPI:1073916540
Name:BLACKWELL, MIRANDA R (MS, LMHP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:R
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MS, LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 S 40TH ST STE 111
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5247
Mailing Address - Country:US
Mailing Address - Phone:402-417-0730
Mailing Address - Fax:531-500-0930
Practice Address - Street 1:1919 S 40TH ST STE 111
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5247
Practice Address - Country:US
Practice Address - Phone:402-417-0730
Practice Address - Fax:531-500-0930
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3481101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health