Provider Demographics
NPI:1275910143
Name:MIRANDA, LESLIE ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ELIZABETH
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 1:1601 CARMEN DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3103
Mailing Address - Country:US
Mailing Address - Phone:805-625-3786
Mailing Address - Fax:805-427-9047
Practice Address - Street 1:1601 CARMEN DR STE 102
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3103
Practice Address - Country:US
Practice Address - Phone:805-625-3786
Practice Address - Fax:805-427-9047
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87594106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist