Provider Demographics
NPI:1215536594
Name:CONLEY, MYRANDA (T-LPC)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
Last Name:CONLEY
Suffix:
Gender:F
Credentials:T-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 N BUCKNER ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2948
Mailing Address - Country:US
Mailing Address - Phone:316-788-6464
Mailing Address - Fax:206-299-1262
Practice Address - Street 1:1525 N BUCKNER ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2948
Practice Address - Country:US
Practice Address - Phone:316-788-6464
Practice Address - Fax:206-299-1262
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03723101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health