Basic Information
| Provider Information | |||||||||
| NPI: | 1265623854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANCU | ||||||||
| FirstName: | MIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENE | ||||||||
| OtherFirstName: | MIRA | ||||||||
| OtherMiddleName: | BRANCU | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.ED., NCC, LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 112 PRIMROSE LN | ||||||||
| Address2: | |||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275105574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192404278 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 508 FULTON ST | ||||||||
| Address2: | DURHAM VAMC | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277053875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192860411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 4061 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 4061 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | 284300000X | 4061 | NC | N | Hospitals | Special Hospital |
No ID Information.