Provider Demographics
NPI:1477943645
Name:DE MIRANDA, COLIN (LCSW)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:DE MIRANDA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 INDUSTRIAL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SMCHS COASTSIDE MENTAL HEALTH CENTER
Practice Address - Street 2:225 SOUTH CABRILLO HIGHWAY, SUITE 200A
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019
Practice Address - Country:US
Practice Address - Phone:650-726-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA1068091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor