Provider Demographics
NPI:1326662727
Name:AGESON, MIRANDA LEIGH (MSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEIGH
Last Name:AGESON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4023 W 234TH PL
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4617
Mailing Address - Country:US
Mailing Address - Phone:714-916-4940
Mailing Address - Fax:
Practice Address - Street 1:10929 SOUTH ST STE 208B
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-5391
Practice Address - Country:US
Practice Address - Phone:562-865-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA103760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator