Provider Demographics
NPI:1760115364
Name:STOUGHTON, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:STOUGHTON
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 1:38 GOUGHES BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-5145
Mailing Address - Country:US
Mailing Address - Phone:407-538-3596
Mailing Address - Fax:
Practice Address - Street 1:38 GOUGHES BRANCH RD
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:NC
Practice Address - Zip Code:28748-5145
Practice Address - Country:US
Practice Address - Phone:407-538-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC122416103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool