Provider Demographics
NPI:1679064620
Name:CHARLES, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:CHARLES
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 1:622 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6211
Mailing Address - Country:US
Mailing Address - Phone:318-398-0945
Mailing Address - Fax:318-398-4314
Practice Address - Street 1:1325 WRIGHT AVE STE D
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2226
Practice Address - Country:US
Practice Address - Phone:337-514-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9201171M00000X, 101Y00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator