Healthcare Provider Details

I. General information

NPI: 1578289963
Provider Name (Legal Business Name): MIRANDA RENEE MESTAS VATTEROTT ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8075 W 3RD ST
LOS ANGELES CA
90048-4318
US

IV. Provider business mailing address

5120 MESMER AVE
CULVER CITY CA
90230-6039
US

V. Phone/Fax

Practice location:
  • Phone: 424-587-5224
  • Fax:
Mailing address:
  • Phone: 310-503-4492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW87839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: