Provider Demographics
NPI:1467767103
Name:MIRANDA, GLORIMAR (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLORIMAR
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00954-0158
Mailing Address - Country:US
Mailing Address - Phone:787-223-9769
Mailing Address - Fax:
Practice Address - Street 1:E11 CALLE 2
Practice Address - Street 2:URB SANTA CRUZ
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6923
Practice Address - Country:US
Practice Address - Phone:787-223-9769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3263103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical