Provider Demographics
NPI:1871279653
Name:WILLIS, MIRANDA (LMSW)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 DIMAGGIO WAY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129
Mailing Address - Country:US
Mailing Address - Phone:270-403-1381
Mailing Address - Fax:
Practice Address - Street 1:123 DIMAGGIO WAY
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:270-403-1381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN123101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical