Basic Information
Provider Information | |||||||||
NPI: | 1326110230 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IRVIN | ||||||||
FirstName: | MIRIAM | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, LLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1485 S M-139 | ||||||||
Address2: |   | ||||||||
City: | BENTON HARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 49022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699250585 | ||||||||
FaxNumber: | 2699271326 | ||||||||
Practice Location | |||||||||
Address1: | 1485 S M-139 | ||||||||
Address2: |   | ||||||||
City: | BENTON HARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 49022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699250585 | ||||||||
FaxNumber: | 2699271326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 03/18/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 6301011675 | MI | N |   | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 101YM0800X | 6401007990 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.