Provider Demographics
NPI:1477098937
Name:IKEMIYASHIRO, MIRIAH
Entity Type:Individual
Prefix:
First Name:MIRIAH
Middle Name:
Last Name:IKEMIYASHIRO
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 1:12993 S SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7805
Mailing Address - Country:US
Mailing Address - Phone:435-760-9020
Mailing Address - Fax:
Practice Address - Street 1:650 E 4500 S STE 300
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4502
Practice Address - Country:US
Practice Address - Phone:435-760-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YS0200X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool