Provider Demographics
NPI:1932924065
Name:COLEMAN, MIRANDA GRACE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:GRACE
Last Name:COLEMAN
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 1:8517 FM 1826 STE 501
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-1472
Mailing Address - Country:US
Mailing Address - Phone:512-732-2511
Mailing Address - Fax:
Practice Address - Street 1:8517 FM 1826 STE 501
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-1472
Practice Address - Country:US
Practice Address - Phone:512-732-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-24-374408106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician