Provider Demographics
NPI:1447956966
Name:NIELSON, MIRA LEE (LPC)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:LEE
Last Name:NIELSON
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 1:635 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4156
Mailing Address - Country:US
Mailing Address - Phone:530-566-4117
Mailing Address - Fax:
Practice Address - Street 1:420 W 4TH S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2319
Practice Address - Country:US
Practice Address - Phone:208-656-4017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8241727101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health