Provider Demographics
NPI:1912771403
Name:VIORST, MIRANDA (APCC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:VIORST
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:
Other - Last Name:VIORST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APCC
Mailing Address - Street 1:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:OCCIDENTAL
Mailing Address - State:CA
Mailing Address - Zip Code:95465-0294
Mailing Address - Country:US
Mailing Address - Phone:720-335-7237
Mailing Address - Fax:
Practice Address - Street 1:7765 HEALDSBURG AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3309
Practice Address - Country:US
Practice Address - Phone:720-335-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC14637101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health