Provider Demographics
NPI:1124533740
Name:HARRIS, MIRANDA (LCSW, MSSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LCSW, MSSW
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:TOBIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2287 ALBRIGHT LN
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-8902
Mailing Address - Country:US
Mailing Address - Phone:248-535-3290
Mailing Address - Fax:
Practice Address - Street 1:12040 RAYMOND CT
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-8069
Practice Address - Country:US
Practice Address - Phone:847-515-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490174171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical