Provider Demographics
NPI:1760973762
Name:MORTON, MIRANDA TAYLOR
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:TAYLOR
Last Name:MORTON
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 1:610 N ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2956
Mailing Address - Country:US
Mailing Address - Phone:319-759-0605
Mailing Address - Fax:
Practice Address - Street 1:4507 N STERLING AVE STE 400
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3860
Practice Address - Country:US
Practice Address - Phone:309-679-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician