Provider Demographics
NPI:1235904657
Name:GONZALEZ, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GONZALEZ
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 1:1901 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-5120
Mailing Address - Country:US
Mailing Address - Phone:817-691-3283
Mailing Address - Fax:
Practice Address - Street 1:1901 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-5120
Practice Address - Country:US
Practice Address - Phone:817-691-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician