Provider Demographics
NPI:1811636103
Name:PRESLEY, MIRANDA LACE
Entity type:Individual
Prefix:MISS
First Name:MIRANDA
Middle Name:LACE
Last Name:PRESLEY
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 1:5550 OLD SHELL RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3039
Mailing Address - Country:US
Mailing Address - Phone:251-287-2242
Mailing Address - Fax:
Practice Address - Street 1:5550 OLD SHELL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3039
Practice Address - Country:US
Practice Address - Phone:251-287-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-22-211098106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician