Provider Demographics
NPI:1982376026
Name:DEATLEY, MIRANDA MARIE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:MARIE
Last Name:DEATLEY
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 1:1746 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-1616
Mailing Address - Country:US
Mailing Address - Phone:507-381-3321
Mailing Address - Fax:
Practice Address - Street 1:501 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6109
Practice Address - Country:US
Practice Address - Phone:507-682-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251S00000XAgenciesCommunity/Behavioral Health