Provider Demographics
NPI:1821640079
Name:MIRANDA, CAITLIN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAITLIN
Middle Name:MARIE
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HARRISON TER
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-4320
Mailing Address - Country:US
Mailing Address - Phone:917-747-5022
Mailing Address - Fax:
Practice Address - Street 1:21 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-4686
Practice Address - Country:US
Practice Address - Phone:631-766-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29705103TC0700X
NY023050103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical