Basic Information
| Provider Information | |||||||||
| NPI: | 1518392489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMNER | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2702348572 | ||||||||
| Practice Location | |||||||||
| Address1: | 4531 HWY 54 STE 1 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423032486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2702404425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 05/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 252696 | KY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.