MEDICARE: MARISELA MIRANDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1407423726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISELA MIRANDA

Provider Business Mailing Address
First Line	:	1461 HILGER ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92114-2112
Country	:	US
Telephone Number	:	619-902-8440
Fax Number	:

Provider Business Practice Location Address
First Line	:	1461 HILGER ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92114-2112
Country	:	US
Telephone Number	:	619-902-8440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2021
Last Update Date	:	06/06/2021

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Directions to “ MARISELA MIRANDA ” Practice Location

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