Provider Demographics
NPI:1356681308
Name:FASSBENDER, MIRANDA MARIE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:FASSBENDER
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 1:2265 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1737
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:651-379-6141
Practice Address - Street 1:230 DERONDA ST
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1412
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1887101YP2500X
WI5640.125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional