Provider Demographics
NPI:1184115404
Name:CICERO, MIRANDA K
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:K
Last Name:CICERO
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 1:5006 W ALBAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9558
Mailing Address - Country:US
Mailing Address - Phone:734-770-7966
Mailing Address - Fax:
Practice Address - Street 1:2086 S CUSTER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1831
Practice Address - Country:US
Practice Address - Phone:734-682-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician