Provider Demographics
NPI:1013684356
Name:LACOMB, MIRANDA K (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:K
Last Name:LACOMB
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 COLLEGE AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6701
Mailing Address - Country:US
Mailing Address - Phone:607-339-6648
Mailing Address - Fax:
Practice Address - Street 1:407 COLLEGE AVE STE 409
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-6701
Practice Address - Country:US
Practice Address - Phone:607-319-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108257104100000X
NY0958831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker