Provider Demographics
NPI:1194541847
Name:MIRANDA COLTER, VICTOR WALTER (MED, LPC)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:WALTER
Last Name:MIRANDA COLTER
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:MR
Other - First Name:VICTOR
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, LPC
Mailing Address - Street 1:9225 RAINBOW FALLS DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2136
Mailing Address - Country:US
Mailing Address - Phone:571-921-0278
Mailing Address - Fax:
Practice Address - Street 1:9225 RAINBOW FALLS DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2136
Practice Address - Country:US
Practice Address - Phone:571-921-0278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701014184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional