Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 115868 | TX |
N | 103TC1900X | Counseling Psychologist | 115868 | TX |
NPI | 1104479930 |
---|---|
Provider Name | John A Miranda |
First Address | San Antonio, TX 78233-6459 |
Second Address | San Antonio, TX 78205-2990 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2019 |
Last Update Date | 18/04/2021 |