Provider Demographics
NPI:1932947512
Name:BRONDER, MIRIAH JENELLE (PPC)
Entity type:Individual
Prefix:
First Name:MIRIAH
Middle Name:JENELLE
Last Name:BRONDER
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 SILVER FOX LN
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-1071
Mailing Address - Country:US
Mailing Address - Phone:913-274-6073
Mailing Address - Fax:
Practice Address - Street 1:1904 WARREN AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3730
Practice Address - Country:US
Practice Address - Phone:307-317-0973
Practice Address - Fax:307-216-4318
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health