Provider Demographics
NPI:1376259259
Name:WILSON, MIRANDA NOELLE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NOELLE
Last Name:WILSON
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 1:1452 PARAMOUNT DR APT 3A
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-2686
Mailing Address - Country:US
Mailing Address - Phone:334-208-0936
Mailing Address - Fax:
Practice Address - Street 1:475 PROVIDENCE MAIN ST NW STE 201
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-4828
Practice Address - Country:US
Practice Address - Phone:256-489-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician