Provider Demographics
NPI:1497266720
Name:MUSSARIO, MIRANDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:MUSSARIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:LUDWIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363542328Medicaid