Provider Demographics
NPI:1578830980
Name:FRAZER, MIRANDA LEE (FSP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEE
Last Name:FRAZER
Suffix:
Gender:F
Credentials:FSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1488 JENICE DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-1121
Mailing Address - Country:US
Mailing Address - Phone:580-247-0169
Mailing Address - Fax:
Practice Address - Street 1:512 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460
Practice Address - Country:US
Practice Address - Phone:580-622-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health