Healthcare Provider Details

I. General information

NPI: 1588580716
Provider Name (Legal Business Name): IDALIA MONTANEZ MIRANDA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
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 TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. IDALIA MONTANEZ-MIRANDA
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSY.D.
Phone: 805-505-7210