Provider Demographics
NPI:1790093250
Name:VERTNIK, MIRANDA RENAE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:RENAE
Last Name:VERTNIK
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 EAGLE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1284
Mailing Address - Country:US
Mailing Address - Phone:952-746-7664
Mailing Address - Fax:
Practice Address - Street 1:8600 EAGLE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1284
Practice Address - Country:US
Practice Address - Phone:952-746-7664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5286103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical