Healthcare Provider Details

I. General information

NPI: 1023303070
Provider Name (Legal Business Name): INNAEL TODD MIRANDA LAC, LPC, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 MORNINGSIDE DR NE
ALBUQUERQUE NM
87110-6172
US

IV. Provider business mailing address

1119 MORNINGSIDE DR NE
ALBUQUERQUE NM
87110-6172
US

V. Phone/Fax

Practice location:
  • Phone: 720-230-3326
  • Fax:
Mailing address:
  • Phone: 720-230-3326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC-7097
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0229
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0020508
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: