Provider Demographics
NPI:1497122477
Name:HOME, MIRIAM
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:HOME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 3RD AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4050
Mailing Address - Country:US
Mailing Address - Phone:650-409-8638
Mailing Address - Fax:650-560-2892
Practice Address - Street 1:205 E 3RD AVE STE 409
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4050
Practice Address - Country:US
Practice Address - Phone:650-409-8638
Practice Address - Fax:650-560-2892
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health