Provider Demographics
NPI:1114148798
Name:DYRDAHL, MIRANDA (PSYD, LMFT, LP)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:DYRDAHL
Suffix:
Gender:F
Credentials:PSYD, LMFT, LP
Other - Prefix:DR
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:GILMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LMT, LP
Mailing Address - Street 1:3333 UNIVERSITY AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3325
Mailing Address - Country:US
Mailing Address - Phone:763-233-7278
Mailing Address - Fax:
Practice Address - Street 1:3333 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414
Practice Address - Country:US
Practice Address - Phone:763-233-7278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPS2010006103T00000X
MNGL0006103TC0700X
CAPSY24149103TC0700X
MN2599106H00000X
CA46860106H00000X
CA51386106H00000X
MNLP5423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist