Provider Demographics
NPI:1164096285
Name:PUENTE, MIRANDA (BSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:PUENTE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1704
Mailing Address - Country:US
Mailing Address - Phone:719-778-4237
Mailing Address - Fax:
Practice Address - Street 1:2521 4TH AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1704
Practice Address - Country:US
Practice Address - Phone:719-778-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12789101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12789OtherBLUE CROSS BLUE SHIELD