Healthcare Provider Details

I. General information

NPI: 1831038249
Provider Name (Legal Business Name): MIRANDA LYNN LUCCHESSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2026
Last Update Date: 03/28/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S LAKE DESTINY RD STE 350
MAITLAND FL
32751-7222
US

IV. Provider business mailing address

1477 ASH CIR APT 103
CASSELBERRY FL
32707-6535
US

V. Phone/Fax

Practice location:
  • Phone: 407-618-0493
  • Fax:
Mailing address:
  • Phone: 407-813-5990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: