Provider Demographics
NPI:1093291189
Name:PORTESI, MIRANDA
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:PORTESI
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1565 W ARROW HWY SPC C6
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5036
Mailing Address - Country:US
Mailing Address - Phone:909-938-5511
Mailing Address - Fax:
Practice Address - Street 1:819 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1703
Practice Address - Country:US
Practice Address - Phone:626-359-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist