Healthcare Provider Details

I. General information

NPI: 1649109299
Provider Name (Legal Business Name): JONALYS LOPEZ MIRANDA MSSP, PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 N MAIN ST # 304
CROWN POINT IN
46307-1877
US

IV. Provider business mailing address

2100 N MAIN ST # 304
CROWN POINT IN
46307-1877
US

V. Phone/Fax

Practice location:
  • Phone: 888-837-5440
  • Fax: 574-546-1999
Mailing address:
  • Phone: 888-837-5440
  • Fax: 574-546-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number20044079A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: