Provider Demographics
NPI:1326603127
Name:MIRANDA 08/29/8708, MARITZA DIONNE
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:DIONNE
Last Name:MIRANDA 08/29/8708
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 1:542 4TH AVE STE B101
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4707
Mailing Address - Country:US
Mailing Address - Phone:907-374-1097
Mailing Address - Fax:
Practice Address - Street 1:542 4TH AVE STE B101
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4707
Practice Address - Country:US
Practice Address - Phone:907-374-1097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)