Provider Demographics
NPI:1497241681
Name:MIRANDA, BRIDGET NICOLE
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:NICOLE
Last Name:MIRANDA
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 1:333 S. BEAUDRY AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017
Mailing Address - Country:US
Mailing Address - Phone:213-241-3841
Mailing Address - Fax:213-241-3305
Practice Address - Street 1:333 S. BEAUDRY AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-241-3841
Practice Address - Fax:213-241-3305
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2023-08-09
Deactivation Date:2021-08-31
Deactivation Code:
Reactivation Date:2021-09-09
Provider Licenses
StateLicense IDTaxonomies
CA1005921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical