Provider Demographics
NPI:1669235081
Name:VAN HORN, MIRANDA LEE (LCSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEE
Last Name:VAN HORN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 E HUDSON DR
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-8536
Mailing Address - Country:US
Mailing Address - Phone:801-455-2250
Mailing Address - Fax:
Practice Address - Street 1:1551 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-5015
Practice Address - Country:US
Practice Address - Phone:801-455-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5575956-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical