Provider Demographics
NPI:1134491962
Name:MIRANDA, OMAR LEE (MED)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:LEE
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 EARL ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30733-9672
Mailing Address - Country:US
Mailing Address - Phone:770-354-2912
Mailing Address - Fax:706-234-4943
Practice Address - Street 1:155 EARL ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:GA
Practice Address - Zip Code:30733-9672
Practice Address - Country:US
Practice Address - Phone:770-354-2912
Practice Address - Fax:706-234-4943
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health