Provider Demographics
NPI:1891389342
Name:PEDERSON, MIRANDA S (CSAC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 S BARSTOW ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3678
Mailing Address - Country:US
Mailing Address - Phone:715-855-5300
Mailing Address - Fax:
Practice Address - Street 1:306 S BARSTOW ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3678
Practice Address - Country:US
Practice Address - Phone:715-855-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16399-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)