Provider Demographics
NPI:1003282104
Name:MIRABUENO, MARJEREEN
Entity Type:Individual
Prefix:
First Name:MARJEREEN
Middle Name:
Last Name:MIRABUENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 MIGNOT LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-2417
Mailing Address - Country:US
Mailing Address - Phone:650-814-0720
Mailing Address - Fax:
Practice Address - Street 1:459 MIGNOT LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-2417
Practice Address - Country:US
Practice Address - Phone:650-814-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12609225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation