Provider Demographics
NPI:1801290408
Name:ACHARYA, MIRANDA TAI CAMPBELL (LCSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:TAI CAMPBELL
Last Name:ACHARYA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 NE COUCH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3052
Mailing Address - Country:US
Mailing Address - Phone:503-753-6373
Mailing Address - Fax:
Practice Address - Street 1:6906 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-6138
Practice Address - Country:US
Practice Address - Phone:971-266-1081
Practice Address - Fax:503-575-3749
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ORL85141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator