Provider Demographics
NPI:1841838208
Name:THOMPSON, MIRANDA RENAE (MED, BCBA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENAE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 DUDLEY PIKE
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-8120
Mailing Address - Country:US
Mailing Address - Phone:859-360-3006
Mailing Address - Fax:
Practice Address - Street 1:6457 ELSINOR CT
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-7990
Practice Address - Country:US
Practice Address - Phone:859-360-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-17-42418106S00000X
1-20-46644103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-46644OtherBCBA