Provider Demographics
NPI:1942947478
Name:GREEN, MIRANDA (LPC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 GREEN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MO
Mailing Address - Zip Code:63077-3443
Mailing Address - Country:US
Mailing Address - Phone:636-584-1205
Mailing Address - Fax:
Practice Address - Street 1:1351 JEFFERSON ST STE 111
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-6449
Practice Address - Country:US
Practice Address - Phone:636-584-1205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020011992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional