Provider Demographics
NPI:1710052618
Name:FANI SROUR, MIRANDA RAE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:RAE
Last Name:FANI SROUR
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:RAE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:4 MERRY MEETING LN
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NH
Mailing Address - Zip Code:03870-2325
Mailing Address - Country:US
Mailing Address - Phone:617-504-5737
Mailing Address - Fax:
Practice Address - Street 1:1145 SAGAMORE AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5585
Practice Address - Country:US
Practice Address - Phone:603-431-6703
Practice Address - Fax:603-430-3753
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1151361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH7706655Y0NH01OtherBHN
NH99003227Medicaid
NHNH3227Medicare ID - Type Unspecified