Provider Demographics
NPI:1952846750
Name:MIRANDA, KELLY MARIE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name: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 1:7540 SW 158TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3304
Mailing Address - Country:US
Mailing Address - Phone:305-496-4227
Mailing Address - Fax:
Practice Address - Street 1:7540 SW 158TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-3304
Practice Address - Country:US
Practice Address - Phone:305-496-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-39427106S00000X
FLBCBA-1-20-45893103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician