Provider Demographics
NPI:1508881772
Name:BEHNKE, MIRANDA MAY (LBSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MAY
Last Name:BEHNKE
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:MAY
Other - Last Name:SHALLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:715 PYLE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4456
Mailing Address - Country:US
Mailing Address - Phone:906-774-0522
Mailing Address - Fax:906-774-1570
Practice Address - Street 1:1409 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3918
Practice Address - Country:US
Practice Address - Phone:715-735-0095
Practice Address - Fax:715-735-0094
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9668-120104100000X
WI18736-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
982471046475OtherPREFERRED ONE
MIMB085458OtherBCBS OF MI