Healthcare Provider Details

I. General information

NPI: 1942589296
Provider Name (Legal Business Name): IDALIA MONTANEZ-MIRANDA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SHIPYARD WAY UNIT 1107
ST AUGUSTINE FL
32084-4239
US

IV. Provider business mailing address

PO BOX 126
ST AUGUSTINE FL
32085-0126
US

V. Phone/Fax

Practice location:
  • Phone: 805-505-7210
  • Fax:
Mailing address:
  • Phone: 805-505-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60898484
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60898484
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: