Provider Demographics
NPI:1659033132
Name:BOARD, MIRANDA P
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:P
Last Name:BOARD
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 1:215 PAYNE RD
Mailing Address - Street 2:
Mailing Address - City:EKRON
Mailing Address - State:KY
Mailing Address - Zip Code:40117-8571
Mailing Address - Country:US
Mailing Address - Phone:502-548-1691
Mailing Address - Fax:
Practice Address - Street 1:402 W LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2011
Practice Address - Country:US
Practice Address - Phone:502-548-1691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician