Basic Information
| Provider Information | |||||||||
| NPI: | 1194889790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRUS | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1103 FORTUNE AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324011831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507696188 | ||||||||
| FaxNumber: | 8507691261 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 FORTUNE AVE | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324011831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507696188 | ||||||||
| FaxNumber: | 8507691261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 106H00000X | MT1140 | FL | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 163WP0808X | RN56361-2 | FL | X | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | Z2167 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |