Provider Demographics
NPI:1235699570
Name:MIRANDA, SHAUNA JOYCE
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:JOYCE
Last Name:MIRANDA
Suffix:
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 1:18124 SEAFORTH ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-7439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18124 SEAFORTH ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-7439
Practice Address - Country:US
Practice Address - Phone:760-686-6838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA128544106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist