Provider Demographics
NPI:1750635603
Name:MATHIS, MIRANDA (LCSW, LSCSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:
Credentials:LCSW, LSCSW
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:500 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64106
Mailing Address - Country:US
Mailing Address - Phone:816-842-8040
Mailing Address - Fax:816-792-3219
Practice Address - Street 1:500 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64106
Practice Address - Country:US
Practice Address - Phone:816-842-8040
Practice Address - Fax:816-792-3219
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240212171041C0700X
KSLSCSW064081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical