Provider Demographics
NPI:1336856137
Name:MACDICKEN, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MACDICKEN
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 1:18111 25TH AVE NE APT W106
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-2902
Mailing Address - Country:US
Mailing Address - Phone:253-306-1755
Mailing Address - Fax:
Practice Address - Street 1:21907 64TH AVE W STE 200
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6200
Practice Address - Country:US
Practice Address - Phone:253-306-1755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC611771601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical