Provider Demographics
NPI:1780433912
Name:MIRANDA, DIEGO JULIAN (LPC)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:JULIAN
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 S WELLS ST STE 107
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7997
Mailing Address - Country:US
Mailing Address - Phone:208-646-1077
Mailing Address - Fax:
Practice Address - Street 1:1047 S WELLS ST STE 107
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7997
Practice Address - Country:US
Practice Address - Phone:208-702-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10507101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor