Provider Demographics
NPI:1346880556
Name:CANTRICK, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:CANTRICK
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 1:8441 PARKLAND ST # 7-203
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4182
Mailing Address - Country:US
Mailing Address - Phone:303-819-0185
Mailing Address - Fax:
Practice Address - Street 1:3005 47TH ST STE F1
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-5550
Practice Address - Country:US
Practice Address - Phone:303-819-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015460101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional