Provider Demographics
NPI:1447658489
Name:NORMAN, MIRKA
Entity type:Individual
Prefix:MRS
First Name:MIRKA
Middle Name:
Last Name:NORMAN
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 1:110 W SANDY LAKE RD
Mailing Address - Street 2:SUITE 102, BOX 101
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2015
Mailing Address - Country:US
Mailing Address - Phone:214-671-8530
Mailing Address - Fax:
Practice Address - Street 1:110 W SANDY LAKE RD
Practice Address - Street 2:SUITE 102, BOX 101
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2015
Practice Address - Country:US
Practice Address - Phone:214-671-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
TX63652104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool