Provider Demographics
NPI:1952038515
Name:SALDIVAR, MIRANDA DESTINY
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:DESTINY
Last Name:SALDIVAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 S NOGALES ST UNIT A104
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-3057
Mailing Address - Country:US
Mailing Address - Phone:833-831-8946
Mailing Address - Fax:
Practice Address - Street 1:4141 S NOGALES ST UNIT A104
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3057
Practice Address - Country:US
Practice Address - Phone:833-831-8946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA831347074Medicaid