Provider Demographics
NPI:1053011874
Name:GREENWOOD, MIRANDA (LPC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GREENWOOD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S 76TH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4352
Mailing Address - Country:US
Mailing Address - Phone:262-442-2782
Mailing Address - Fax:
Practice Address - Street 1:4811 S 76TH ST STE 208
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4352
Practice Address - Country:US
Practice Address - Phone:262-442-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10291-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health