Provider Demographics
NPI:1619232154
Name:MIDDONA, MIRANDA LYN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:LYN
Last Name:MIDDONA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 KINDBERG COURT
Mailing Address - Street 2:
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119
Mailing Address - Country:US
Mailing Address - Phone:630-365-4211
Mailing Address - Fax:
Practice Address - Street 1:913 KINDBERG COURT
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119
Practice Address - Country:US
Practice Address - Phone:630-365-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149015352101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker