Provider Demographics
NPI:1144712209
Name:MENARD, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MENARD
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 1:18 PRISCILLA LN
Mailing Address - Street 2:
Mailing Address - City:ROUSES POINT
Mailing Address - State:NY
Mailing Address - Zip Code:12979-1454
Mailing Address - Country:US
Mailing Address - Phone:518-536-0881
Mailing Address - Fax:
Practice Address - Street 1:31 6TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1246
Practice Address - Country:US
Practice Address - Phone:518-483-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY0941971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker