Healthcare Provider Details

I. General information

NPI: 1962697011
Provider Name (Legal Business Name): HEATHER KRISTEN MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

PO BOX 28220
SANTA FE NM
87592-8220
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-5006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0104651
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0129911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: