Provider Demographics
NPI:1336527738
Name:CHICK-LAMB, MIRANDA JANE (BCBA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JANE
Last Name:CHICK-LAMB
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:JANE
Other - Last Name:CHICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:542 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1016
Mailing Address - Country:US
Mailing Address - Phone:561-323-6593
Mailing Address - Fax:
Practice Address - Street 1:15000 COMMERCE PKWY STE C
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2212
Practice Address - Country:US
Practice Address - Phone:855-647-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-23-67837103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1396169579Medicaid
NJ0400084Medicare PIN