Provider Demographics
NPI:1780080150
Name:MIRANDA, LUIS ENRIQUE (MRC)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ENRIQUE
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CONDADO MODERNO 1 C-17
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-2420
Mailing Address - Country:US
Mailing Address - Phone:939-239-3959
Mailing Address - Fax:
Practice Address - Street 1:INDUSTRIAL MINILLAS 170, 63, PR-174
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-993-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR722101Y00000X, 101YP2500X, 225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional