Provider Demographics
NPI:1669801023
Name:MIRANDA, JOHNNY (BA)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 NORMAN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-5003
Mailing Address - Country:US
Mailing Address - Phone:413-736-8329
Mailing Address - Fax:
Practice Address - Street 1:2155 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3301
Practice Address - Country:US
Practice Address - Phone:413-736-0395
Practice Address - Fax:413-734-1651
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042622756OtherCOMMONWEALTH CARE ALLIANCE
MA1307576OtherMBHP
MA12529OtherHEALTH NEW ENGLAND
MA1307576Medicaid
MA8443OtherBMC
MA1022610OtherNHP
MA1022610OtherFALLON
MA997203OtherNETWORK HEALTH
MAY10086OtherMEDICARE
MA1022610OtherBEACON/BMC
MA71756OtherTUFTS