Provider Demographics
NPI:1134519010
Name:MIRANDA, CARMEN
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:
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 1:12 CALLE CASCADA
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-3610
Mailing Address - Country:US
Mailing Address - Phone:787-625-2900
Mailing Address - Fax:787-760-2944
Practice Address - Street 1:RR 2 BOX 11
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-9767
Practice Address - Country:US
Practice Address - Phone:787-625-2900
Practice Address - Fax:787-760-2944
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5633101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)