Provider Demographics
NPI:1437413002
Name:MIRANDA, EDMUND M (MA, LAC, LPC)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:M
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MA, LAC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 ELIZABETH WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-1532
Mailing Address - Country:US
Mailing Address - Phone:719-722-4756
Mailing Address - Fax:
Practice Address - Street 1:5350 TOMAH DR STE 3600
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6991
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000479101YA0400X
171M00000X
COLPC.0012699101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator