Provider Demographics
NPI:1699851352
Name:MIRANDA, CARLA YVETTE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:YVETTE
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-2601
Mailing Address - Country:US
Mailing Address - Phone:501-843-3363
Mailing Address - Fax:
Practice Address - Street 1:602 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2601
Practice Address - Country:US
Practice Address - Phone:501-843-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116049721Medicaid