Provider Demographics
NPI:1689309106
Name:SANTIAGO MIRANDA, LUANY TATIANA
Entity Type:Individual
Prefix:
First Name:LUANY
Middle Name:TATIANA
Last Name:SANTIAGO MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15301 WHITE TAIL LOOP
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-9007
Mailing Address - Country:US
Mailing Address - Phone:407-955-2897
Mailing Address - Fax:
Practice Address - Street 1:7441 114TH AVE STE 604
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5124
Practice Address - Country:US
Practice Address - Phone:727-492-5369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst