Provider Demographics
NPI:1174204796
Name:MIRANDA, NOEL INDEFENSO JR
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:INDEFENSO
Last Name:MIRANDA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NOEL
Other - Middle Name:MANUEL
Other - Last Name:MIRANDA
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:506 N MAPLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-6917
Mailing Address - Country:US
Mailing Address - Phone:650-745-6676
Mailing Address - Fax:
Practice Address - Street 1:2500 REDHILL AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5518
Practice Address - Country:US
Practice Address - Phone:949-748-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-23-285385106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty