Provider Demographics
NPI:1699250092
Name:BUSCH, MIRANDA KAYLIN
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:KAYLIN
Last Name:BUSCH
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 1:523 CATRON ST N UNIT 5
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6876
Practice Address - Country:US
Practice Address - Phone:971-236-0915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst