Provider Demographics
NPI:1275923500
Name:MIRANDA, EDNA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
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:URB SIERRA BAYAMON 35 9 CALLE 34
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00961
Mailing Address - Country:UM
Mailing Address - Phone:787-477-2532
Mailing Address - Fax:
Practice Address - Street 1:URB SIERRA BAYAMON 35 9 CALLE 34
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00961
Practice Address - Country:UM
Practice Address - Phone:787-477-2532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR108031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical