Healthcare Provider Details

I. General information

NPI: 1336447820
Provider Name (Legal Business Name): KRISTIAN DANIEL MIRANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23228 MADERO
MISSION VIEJO CA
92691-2706
US

IV. Provider business mailing address

23228 MADERO
MISSION VIEJO CA
92691-2706
US

V. Phone/Fax

Practice location:
  • Phone: 949-454-3940
  • Fax: 949-770-1953
Mailing address:
  • Phone: 949-454-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: