Provider Demographics
NPI:1124543673
Name:MIRANDA, MARILYNN (PHD)
Entity Type:Individual
Prefix:
First Name:MARILYNN
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 RES HATO GRANDE APT 51
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754-4110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1551 CALLE VICTORIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00912-3123
Practice Address - Country:US
Practice Address - Phone:787-722-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-06
Last Update Date:2017-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3262103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling