Provider Demographics
NPI:1255713186
Name:TRELEAVEN, MIRANDA SHARON (MS)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SHARON
Last Name:TRELEAVEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 BIG HORN BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1240
Mailing Address - Country:US
Mailing Address - Phone:707-310-2012
Mailing Address - Fax:
Practice Address - Street 1:9201 BIG HORN BLVD FL 2
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1240
Practice Address - Country:US
Practice Address - Phone:916-226-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-27
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82355106H00000X, 101Y00000X
CA111476106H00000X
CA7682101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional