Provider Demographics
NPI:1952327207
Name:MIRANDA, CAROLINE (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 S CAROLINA ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-6734
Mailing Address - Country:US
Mailing Address - Phone:310-833-6955
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST.
Practice Address - Street 2:BOX 498
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90509
Practice Address - Country:US
Practice Address - Phone:310-222-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS19554104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ56920Medicare UPIN
CAWSW19554AMedicare ID - Type Unspecified