Provider Demographics
NPI:1265076616
Name:MCQUEEN, MIRANDA L (RADT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:MCQUEEN
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 SUNRISE AVENUE
Mailing Address - Street 2:BUILDING 200, STE-201
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-782-3737
Mailing Address - Fax:
Practice Address - Street 1:730 SUNRISE AVENUE
Practice Address - Street 2:BUILDING 200, STE-201
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-782-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR12303860516101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)