Provider Demographics
NPI:1275082695
Name:WELBORN, MYRANDA (BS)
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
Last Name:WELBORN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 POPLAR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9341
Mailing Address - Country:US
Mailing Address - Phone:704-682-2714
Mailing Address - Fax:
Practice Address - Street 1:2220 POPLAR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9341
Practice Address - Country:US
Practice Address - Phone:704-682-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician