Provider Demographics
NPI:1427545847
Name:PERRERO, MIRANDA L (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:PERRERO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:SHRYACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1008 TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-3523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1008 TIMBER DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-3523
Practice Address - Country:US
Practice Address - Phone:309-337-1318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490230621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical