Provider Demographics
NPI:1891159281
Name:MIRANDA, ANGELINA R (IMF)
Entity Type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:R
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 E MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5212
Mailing Address - Country:US
Mailing Address - Phone:619-441-1907
Mailing Address - Fax:
Practice Address - Street 1:1679 E MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5212
Practice Address - Country:US
Practice Address - Phone:760-637-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102996106H00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program