Provider Demographics
NPI:1609106103
Name:FREAR, MIRANDA RAE (LAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RAE
Last Name:FREAR
Suffix:
Gender:F
Credentials:LAC
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 9556
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-9556
Mailing Address - Country:US
Mailing Address - Phone:503-939-0802
Mailing Address - Fax:888-410-1626
Practice Address - Street 1:1361 ELM ST STE 5
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-0920
Practice Address - Country:US
Practice Address - Phone:503-939-0802
Practice Address - Fax:888-410-1626
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT50656171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist