Provider Demographics
NPI:1194598177
Name:CLARK, MIRANDA PAIGE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:PAIGE
Last Name:CLARK
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 1:6066 CEDAR HILL LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1046
Mailing Address - Country:US
Mailing Address - Phone:513-257-9064
Mailing Address - Fax:
Practice Address - Street 1:6066 CEDAR HILL LN
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1046
Practice Address - Country:US
Practice Address - Phone:513-257-9064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY274268101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)