Healthcare Provider Details

I. General information

NPI: 1174018774
Provider Name (Legal Business Name): JULY MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 W 19TH ST
CHICAGO IL
60608-2512
US

IV. Provider business mailing address

2309 W 19TH ST
CHICAGO IL
60608-2512
US

V. Phone/Fax

Practice location:
  • Phone: 312-593-6597
  • Fax:
Mailing address:
  • Phone: 312-593-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: