Provider Demographics
NPI:1629716576
Name:MBURU, MIRIAM W (LGPC)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:W
Last Name:MBURU
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 BRUBAR CT
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5826
Mailing Address - Country:US
Mailing Address - Phone:202-854-8908
Mailing Address - Fax:
Practice Address - Street 1:720 MAIDEN CHOICE LN # C
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5940
Practice Address - Country:US
Practice Address - Phone:202-854-8908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-21
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health