Provider Demographics
NPI:1790521037
Name:VENOSDLE, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:VENOSDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14000 LINCOLN ST SE LOT 12
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-8948
Mailing Address - Country:US
Mailing Address - Phone:234-427-9031
Mailing Address - Fax:
Practice Address - Street 1:14000 LINCOLN ST SE LOT 12
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8948
Practice Address - Country:US
Practice Address - Phone:740-291-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTX686038103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service