Provider Demographics
NPI:1871686105
Name:GOLDFARB, MIRANDA (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:
Last Name:GOLDFARB
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-0374
Mailing Address - Country:US
Mailing Address - Phone:530-615-1611
Mailing Address - Fax:
Practice Address - Street 1:180 SIERRA COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5768
Practice Address - Country:US
Practice Address - Phone:530-273-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1121251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical