Provider Demographics
NPI:1447989520
Name:SICKING, MIRANDA L
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:SICKING
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 1:815 S DONAGHEY AVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6880
Mailing Address - Country:US
Mailing Address - Phone:501-441-2096
Mailing Address - Fax:
Practice Address - Street 1:815 S DONAGHEY AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6880
Practice Address - Country:US
Practice Address - Phone:501-441-2096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician