Provider Demographics
NPI:1639635956
Name:LUCE, MIRANDA ELIZABETH
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELIZABETH
Last Name:LUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 GLEN FOREST DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6106
Mailing Address - Country:US
Mailing Address - Phone:321-446-1846
Mailing Address - Fax:
Practice Address - Street 1:420 THE PKWY STE J
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-5205
Practice Address - Country:US
Practice Address - Phone:864-244-3474
Practice Address - Fax:864-244-3475
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
SC7731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician