Provider Demographics
NPI:1659053965
Name:LEATUTUFU, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:LEATUTUFU
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 1:4527 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2216
Mailing Address - Country:US
Mailing Address - Phone:907-360-9067
Mailing Address - Fax:
Practice Address - Street 1:4600 DEBARR RD
Practice Address - Street 2:SUITE 201-M
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3103
Practice Address - Country:US
Practice Address - Phone:907-222-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health