Provider Demographics
NPI:1558957043
Name:GONZALES, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 STERLING LN
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01835-8403
Mailing Address - Country:US
Mailing Address - Phone:978-994-9530
Mailing Address - Fax:
Practice Address - Street 1:18 STERLING LN
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:MA
Practice Address - Zip Code:01835-8403
Practice Address - Country:US
Practice Address - Phone:978-994-9530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician