Provider Demographics
NPI:1740911379
Name:MCDONALD, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:BROUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8629 BLUEJACKET ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1604
Mailing Address - Country:US
Mailing Address - Phone:913-677-3553
Mailing Address - Fax:913-677-3282
Practice Address - Street 1:7829 E ROCKHILL ST STE 105
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3919
Practice Address - Country:US
Practice Address - Phone:316-221-5545
Practice Address - Fax:913-677-3282
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health