Healthcare Provider Details

I. General information

NPI: 1578491189
Provider Name (Legal Business Name): MRS. MARTHA MIRANDA SR.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 W SAN BERNARDINO RD APT D
COVINA CA
91722-3460
US

IV. Provider business mailing address

1419 W SAN BERNARDINO RD APT D
COVINA CA
91722-3460
US

V. Phone/Fax

Practice location:
  • Phone: 626-339-4999
  • Fax:
Mailing address:
  • Phone: 626-339-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: