Provider Demographics
NPI:1912385329
Name:LLANO, MIRANDA JMK
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:JMK
Last Name:LLANO
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 1:311 PETTIGRU ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3112
Mailing Address - Country:US
Mailing Address - Phone:864-915-8109
Mailing Address - Fax:
Practice Address - Street 1:311 PETTIGRU ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3112
Practice Address - Country:US
Practice Address - Phone:864-915-8109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid