Provider Demographics
NPI:1578073573
Name:DICKESS, MIRANDA A (LISW-S)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:A
Last Name:DICKESS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-0108
Mailing Address - Country:US
Mailing Address - Phone:740-532-1613
Mailing Address - Fax:740-532-1715
Practice Address - Street 1:700 PARK AVE
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638
Practice Address - Country:US
Practice Address - Phone:740-532-1613
Practice Address - Fax:740-532-1715
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701362104100000X
OHI.20023591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0290702Medicaid