Healthcare Provider Details

I. General information

NPI: 1477005056
Provider Name (Legal Business Name): CARRIE MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4359 KUKUI GROVE ST STE 102
LIHUE HI
96766-2008
US

IV. Provider business mailing address

140 W FRANKLIN ST UNIT 202
MONTEREY CA
93940-2725
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6070
  • Fax: 800-991-6071
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA-267
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: