Provider Demographics
NPI:1184192163
Name:BLATCHFORD, MIRANDA FRANCES (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:FRANCES
Last Name:BLATCHFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1490
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-1490
Mailing Address - Country:US
Mailing Address - Phone:928-729-4012
Mailing Address - Fax:928-729-4200
Practice Address - Street 1:.5 MILES SW OF THE FD FIELD HOUSE
Practice Address - Street 2:BLDG #6905
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-4012
Practice Address - Fax:928-729-4200
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-055261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical