Provider Demographics
NPI:1104239466
Name:MEOLA, MIRANDA R (LCDC III)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:R
Last Name:MEOLA
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 W PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6674
Mailing Address - Country:US
Mailing Address - Phone:440-344-3368
Mailing Address - Fax:
Practice Address - Street 1:1484 STATE ROUTE 46 N
Practice Address - Street 2:SUITE 7
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-8145
Practice Address - Country:US
Practice Address - Phone:440-624-4033
Practice Address - Fax:440-624-4086
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility