Provider Demographics
NPI:1235589755
Name:MANSO, MIRIAM ESTHER I
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:ESTHER
Last Name:MANSO
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W 59TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6894
Mailing Address - Country:US
Mailing Address - Phone:786-768-8020
Mailing Address - Fax:
Practice Address - Street 1:1700 W 59 ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:786-768-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLBACB319341103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst