Provider Demographics
NPI:1750588364
Name:BOHLKEN, MIRANDA SUE (LISW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SUE
Last Name:BOHLKEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3429 HEMLOCK PL NE
Mailing Address - Street 2:APT. 1
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-8816
Mailing Address - Country:US
Mailing Address - Phone:563-581-2673
Mailing Address - Fax:866-387-3989
Practice Address - Street 1:655 LIBERTY WAY
Practice Address - Street 2:SUITE 6
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9154
Practice Address - Country:US
Practice Address - Phone:319-665-2137
Practice Address - Fax:319-665-2137
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA062641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical