Healthcare Provider Details

I. General information

NPI: 1093287872
Provider Name (Legal Business Name): RAVEN MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 AIRPORT RD
FITCHBURG MA
01420-8142
US

IV. Provider business mailing address

277 BALDWINVILLE RD
TEMPLETON MA
01468-1443
US

V. Phone/Fax

Practice location:
  • Phone: 978-343-6300
  • Fax: 978-343-2803
Mailing address:
  • Phone: 978-398-3565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: