1184192163 NPI number — MIRANDA FRANCES BLATCHFORD LCSW

Table of content: MIRANDA FRANCES BLATCHFORD LCSW (NPI 1184192163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184192163 NPI number — MIRANDA FRANCES BLATCHFORD LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLATCHFORD
Provider First Name:
MIRANDA
Provider Middle Name:
FRANCES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184192163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1490
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DEFIANCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86504-1490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-729-4012
Provider Business Mailing Address Fax Number:
928-729-4200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
.5 MILES SW OF THE FD FIELD HOUSE
Provider Second Line Business Practice Location Address:
BLDG #6905
Provider Business Practice Location Address City Name:
FORT DEFIANCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-729-4012
Provider Business Practice Location Address Fax Number:
928-729-4200
Provider Enumeration Date:
11/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C-05526 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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