Provider Demographics
NPI:1639496995
Name:DENNIS, MIRANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:DENNIS
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 1:3131 AZALEA GARDEN RD # B
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-2303
Mailing Address - Country:US
Mailing Address - Phone:757-271-9030
Mailing Address - Fax:
Practice Address - Street 1:3131 AZALEA GARDEN RD # B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23513
Practice Address - Country:US
Practice Address - Phone:757-271-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY89681621041C0700X
VA09040079801041C0700X
NY0810151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical