Provider Demographics
NPI:1720259781
Name:ELIZONDO, MIRIAM MARTINEZ (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:MARTINEZ
Last Name:ELIZONDO
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 N MAIN AVE STE 740
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5711
Mailing Address - Country:US
Mailing Address - Phone:210-271-7411
Mailing Address - Fax:210-271-9411
Practice Address - Street 1:8527 BRAUN KNL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-5584
Practice Address - Country:US
Practice Address - Phone:210-521-9469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62118101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional