Provider Demographics
NPI:1083376289
Name:KARL, MIRANDA MADISON (SAC-IT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MADISON
Last Name:KARL
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:MADISON
Other - Last Name:MANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC-IT
Mailing Address - Street 1:1991 E WINNEBAGO STREET
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501
Mailing Address - Country:US
Mailing Address - Phone:715-362-5745
Mailing Address - Fax:
Practice Address - Street 1:1991 E WINNEBAGO STREET
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501
Practice Address - Country:US
Practice Address - Phone:715-362-5745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)