Provider Demographics
NPI:1194889790
Name:MIRUS, CAROL S
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:S
Last Name:MIRUS
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 1:1103 FORTUNE AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-1831
Mailing Address - Country:US
Mailing Address - Phone:850-769-6188
Mailing Address - Fax:850-769-1261
Practice Address - Street 1:1103 FORTUNE AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1831
Practice Address - Country:US
Practice Address - Phone:850-769-6188
Practice Address - Fax:850-769-1261
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1140106H00000X
FLRN56361-2163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2167OtherBLUE CROSS BLUE SHIELD