Provider Demographics
NPI:1477070142
Name:VILLARD, MIRANDA JO (LPCC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JO
Last Name:VILLARD
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 PEARL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3256
Mailing Address - Country:US
Mailing Address - Phone:330-220-9679
Mailing Address - Fax:
Practice Address - Street 1:1839 PEARL RD STE 101
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3256
Practice Address - Country:US
Practice Address - Phone:330-220-9679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.17400414101YM0800X
OHE.2303541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty