Provider Demographics
NPI:1982480034
Name:MIRANDA MUNGUIA, KATHERINE MARIE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:MIRANDA MUNGUIA
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 1:2202 FLAGLER PROMENADE WAY APT 302
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-8676
Mailing Address - Country:US
Mailing Address - Phone:305-542-6061
Mailing Address - Fax:
Practice Address - Street 1:1112 MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5310
Practice Address - Country:US
Practice Address - Phone:407-625-5836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-240487106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician