Provider Demographics
NPI:1669555314
Name:AMARIS, MIRANDA (MIRANDA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:AMARIS
Suffix:
Gender:F
Credentials:MIRANDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 TRANSIT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2336 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-4343
Practice Address - Country:US
Practice Address - Phone:651-765-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4391103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN143485OtherUCARE
MN463R4AMOtherBLUE CROSS BLUE SHIELD
MN164838100Medicaid
MN20281-10OtherBHP
MN20281-10OtherBHP