Provider Demographics
NPI:1952629131
Name:STOLL, MIRANDA ELLEN (LMHP, PLADC)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:ELLEN
Last Name:STOLL
Suffix:
Gender:F
Credentials:LMHP, PLADC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:ELLEN
Other - Last Name:KOEPKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PLMHP, PLADC
Mailing Address - Street 1:110 N BAILEY
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101
Mailing Address - Country:US
Mailing Address - Phone:308-534-6029
Mailing Address - Fax:308-534-6961
Practice Address - Street 1:110 N BAILEY
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101
Practice Address - Country:US
Practice Address - Phone:308-534-6029
Practice Address - Fax:308-534-6961
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9088101YM0800X
NE3892101YM0800X
NEP-877101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025777100Medicaid