Provider Demographics
NPI:1053016600
Name:PALMER, MIRANDA ROSS (LPC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROSS
Last Name:PALMER
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 1:7660 W MANORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-3555
Mailing Address - Country:US
Mailing Address - Phone:208-409-0083
Mailing Address - Fax:
Practice Address - Street 1:429 SW 5TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5037
Practice Address - Country:US
Practice Address - Phone:208-490-2234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional