Provider Demographics
NPI:1164000626
Name:DAHL, MIRANDA LOU
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LOU
Last Name:DAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:LOU
Other - Last Name:DAHL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8721 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-2720
Mailing Address - Country:US
Mailing Address - Phone:218-340-7416
Mailing Address - Fax:
Practice Address - Street 1:4140 RICHARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-3309
Practice Address - Country:US
Practice Address - Phone:218-514-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician