Provider Demographics
NPI:1629644984
Name:MIRANDA LAMADRID, MIRIAM AUDELINA (APCC)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:AUDELINA
Last Name:MIRANDA LAMADRID
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12536 PENSKE ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5207
Mailing Address - Country:US
Mailing Address - Phone:951-965-0617
Mailing Address - Fax:
Practice Address - Street 1:12968 FREDERICK ST STE A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5229
Practice Address - Country:US
Practice Address - Phone:951-242-7738
Practice Address - Fax:951-208-0409
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC9172101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)