Provider Demographics
NPI:1851120844
Name:FIFIELD, MIRANDA JO
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JO
Last Name:FIFIELD
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 1:21 SMOKEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROZET
Mailing Address - State:WY
Mailing Address - Zip Code:82727-8424
Mailing Address - Country:US
Mailing Address - Phone:605-515-0140
Mailing Address - Fax:
Practice Address - Street 1:201 W LAKEWAY RD STE 600
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6314
Practice Address - Country:US
Practice Address - Phone:307-217-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1486101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty