Provider Demographics
NPI:1346020153
Name:LEE, MIRANDA NICHOLE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICHOLE
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1361
Mailing Address - Country:US
Mailing Address - Phone:320-877-7074
Mailing Address - Fax:
Practice Address - Street 1:349 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1361
Practice Address - Country:US
Practice Address - Phone:320-877-7074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician