Provider Demographics
NPI:1760990402
Name:KORTH, MIRANDA BELLE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:BELLE
Last Name:KORTH
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 1:1613 PROSPECT PARKWAY
Mailing Address - Street 2:110
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1613 PROSPECT PARKWAY
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-377-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-19-37458103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician