Provider Demographics
NPI:1720234263
Name:BOWERSOX, MIRANDA JEAN (MFT)
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:JEAN
Last Name:BOWERSOX
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MRS
Other - First Name:MIRANDA
Other - Middle Name:JEAN
Other - Last Name:BOWERSOX-MOREHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:100 E SAN MARCOS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2988
Mailing Address - Country:US
Mailing Address - Phone:760-566-7738
Mailing Address - Fax:760-919-3139
Practice Address - Street 1:100 E SAN MARCOS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2988
Practice Address - Country:US
Practice Address - Phone:760-566-7738
Practice Address - Fax:760-919-3139
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51423106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist