Provider Demographics
NPI:1023186970
Name:MIRANDA, CYNTHIA (PSYD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1608
Mailing Address - Country:US
Mailing Address - Phone:619-564-8765
Mailing Address - Fax:619-564-8786
Practice Address - Street 1:4060 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1608
Practice Address - Country:US
Practice Address - Phone:619-564-8765
Practice Address - Fax:619-564-8786
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21188103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC18880FOtherMEDI
W5740Medicare ID - Type Unspecified