Provider Demographics
NPI:1457311243
Name:PHELPS, MIRANDA RING (PSYD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RING
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:R
Other - Last Name:RING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 DRESDEN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2615
Mailing Address - Country:US
Mailing Address - Phone:207-621-9337
Mailing Address - Fax:207-621-3609
Practice Address - Street 1:30 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4624
Practice Address - Country:US
Practice Address - Phone:207-872-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS948103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM7466Medicare ID - Type Unspecified