Provider Demographics
NPI:1245616259
Name:SLATER, MIRANDA (LCMHC, LCAS)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:
Last Name:SLATER
Suffix:
Gender:F
Credentials:LCMHC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N FRONT ST STE 215
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-5095
Mailing Address - Country:US
Mailing Address - Phone:910-616-3316
Mailing Address - Fax:
Practice Address - Street 1:12 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4537
Practice Address - Country:US
Practice Address - Phone:910-765-1003
Practice Address - Fax:910-765-1004
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20590101YA0400X
NCA10746101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)