Provider Demographics
NPI:1578289963
Name:VATTEROTT, MIRANDA RENEE MESTAS (ASW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENEE MESTAS
Last Name:VATTEROTT
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 MESMER AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6039
Mailing Address - Country:US
Mailing Address - Phone:310-503-4492
Mailing Address - Fax:
Practice Address - Street 1:8075 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4318
Practice Address - Country:US
Practice Address - Phone:424-587-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW87839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker