Provider Demographics
NPI:1104479930
Name:MIRANDA, JOHN A (LPC, LCDC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ENCANTA ST APT 402
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-6459
Mailing Address - Country:US
Mailing Address - Phone:726-300-4948
Mailing Address - Fax:210-451-0492
Practice Address - Street 1:110 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2990
Practice Address - Country:US
Practice Address - Phone:210-414-4327
Practice Address - Fax:210-451-0492
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115868103TC1900X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty