Provider Demographics
NPI:1689238214
Name:BOAM, MIRANDA LAREE
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:LAREE
Last Name:BOAM
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 1:131 IPUKULA WAY
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-1779
Mailing Address - Country:US
Mailing Address - Phone:360-977-1661
Mailing Address - Fax:
Practice Address - Street 1:553 WAINEE ST
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-1109
Practice Address - Country:US
Practice Address - Phone:360-977-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician