Provider Demographics
NPI:1447589817
Name:MIRANDA, LYDIA (CPRSS)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:CPRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 E SUTHERLAND ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-4041
Mailing Address - Country:US
Mailing Address - Phone:580-477-2871
Mailing Address - Fax:580-477-2870
Practice Address - Street 1:710 E SUTHERLAND ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-4041
Practice Address - Country:US
Practice Address - Phone:580-477-2871
Practice Address - Fax:580-477-2870
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK904208103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst