Provider Demographics
NPI:1659758399
Name:MIRANDA FONSECA, DANIEL (MSW)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MIRANDA FONSECA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COND MAGNOLIA GDNS
Mailing Address - Street 2:P-12
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-7100
Mailing Address - Country:US
Mailing Address - Phone:787-785-9282
Mailing Address - Fax:787-200-0482
Practice Address - Street 1:COND MAGNOLIA GDNS
Practice Address - Street 2:P-12
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-7100
Practice Address - Country:US
Practice Address - Phone:787-785-9282
Practice Address - Fax:787-200-0482
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR128421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12842OtherLICENSE