Provider Demographics
NPI:1316487978
Name:MIRIELLE THERAPY PRACTICE, PLLC
Entity type:Organization
Organization Name:MIRIELLE THERAPY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:212-545-9901
Mailing Address - Street 1:303 5TH AVE
Mailing Address - Street 2:SUITE 1909
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6601
Mailing Address - Country:US
Mailing Address - Phone:212-545-9901
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE
Practice Address - Street 2:SUITE 1909
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6601
Practice Address - Country:US
Practice Address - Phone:212-545-9901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018801-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty