Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | ||
N | 225400000X | Rehabilitation Practitioner |
NPI | 1023641784 |
---|---|
Provider Name | Andrew Miranda |
First Address | Marina Del Rey, CA 90292-5620 |
Second Address | Pasadena, CA 91105-2711 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2020 |
Last Update Date | 28/05/2021 |