Provider Demographics
NPI:1619535358
Name:MERIDA MIRANDA, OLIVER AURELIO
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:AURELIO
Last Name:MERIDA MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 BALBOA BLVD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:ENCINCO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:310-933-4499
Mailing Address - Fax:
Practice Address - Street 1:5435 BALBOA BLVD
Practice Address - Street 2:SUITE #202
Practice Address - City:ENCINCO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:310-933-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst