Provider Demographics
NPI:1104202746
Name:MIRANDA, MAILIN
Entity Type:Individual
Prefix:
First Name:MAILIN
Middle Name:
Last Name:MIRANDA
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 1:282 S CAMINO DEL PUEBLO STE 2C
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5913
Mailing Address - Country:US
Mailing Address - Phone:505-288-3897
Mailing Address - Fax:
Practice Address - Street 1:717 W ABRAHAMES RD STE D
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-8197
Practice Address - Country:US
Practice Address - Phone:505-384-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLMHC 0173981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health