Provider Demographics
NPI:1356069298
Name:MINCHILLO, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MINCHILLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 S MATANZAS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3010
Mailing Address - Country:US
Mailing Address - Phone:813-250-0482
Mailing Address - Fax:
Practice Address - Street 1:217 S MATANZAS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3010
Practice Address - Country:US
Practice Address - Phone:813-250-0482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-223768106S00000X
FL0-25-15820106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician