Provider Demographics
NPI:1104008432
Name:ANTONIO, MIRANDA DAWN (AA)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:DAWN
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 PECOS RD
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-9666
Mailing Address - Country:US
Mailing Address - Phone:505-379-4838
Mailing Address - Fax:
Practice Address - Street 1:253 PECOS RD
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-9666
Practice Address - Country:US
Practice Address - Phone:505-379-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor