Provider Demographics
NPI:1205408374
Name:MIRANDA, MELISSA (MA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 S ALAFAYA TRL # 259
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8732
Mailing Address - Country:US
Mailing Address - Phone:321-529-9405
Mailing Address - Fax:
Practice Address - Street 1:4555 HOFFNER AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812
Practice Address - Country:US
Practice Address - Phone:321-529-9405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT3536106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist