Provider Demographics
NPI:1871687491
Name:BOTTS, MIRANDA K (MA, LPC, LAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:K
Last Name:BOTTS
Suffix:
Gender:F
Credentials:MA, LPC, LAC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:K
Other - Last Name:MOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, LAC
Mailing Address - Street 1:2820 KEYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-6011
Mailing Address - Country:US
Mailing Address - Phone:970-201-8911
Mailing Address - Fax:
Practice Address - Street 1:515 28 3/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5016
Practice Address - Country:US
Practice Address - Phone:970-241-6023
Practice Address - Fax:970-242-8330
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO180101YA0400X
CO4787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)