Provider Demographics
NPI:1083819122
Name:CACERES, MIRIAM
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:CACERES
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 1:1061 GRANT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803
Mailing Address - Country:US
Mailing Address - Phone:914-813-1503
Mailing Address - Fax:
Practice Address - Street 1:545 W 236TH ST STE C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1782
Practice Address - Country:US
Practice Address - Phone:646-574-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY016829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016829OtherNYS LICENSE #