Provider Demographics
NPI:1639688492
Name:BABL, MIRANDA TINA MARTHA (LPC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:TINA MARTHA
Last Name:BABL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5207
Mailing Address - Country:US
Mailing Address - Phone:715-574-9628
Mailing Address - Fax:
Practice Address - Street 1:901 N 6TH ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4718
Practice Address - Country:US
Practice Address - Phone:715-848-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3674-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional