Provider Demographics
NPI:1134894983
Name:KOBER, MIRANDA MARIE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:KOBER
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:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:GODDARD
Mailing Address - State:KS
Mailing Address - Zip Code:67052-0354
Mailing Address - Country:US
Mailing Address - Phone:316-730-3647
Mailing Address - Fax:
Practice Address - Street 1:1400 TERRADYNE DR STE 209
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-7941
Practice Address - Country:US
Practice Address - Phone:316-730-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03291-T106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist