Healthcare Provider Details

I. General information

NPI: 1720161045
Provider Name (Legal Business Name): VILMA ALICIA MIRANDA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2064 BOSTON RD VIDA GUIDANCE CENTER
BRONX NY
10460-2204
US

IV. Provider business mailing address

239 E MOSHOLU PKWY NORTH APT #4H
BRONX NY
10467
US

V. Phone/Fax

Practice location:
  • Phone: 718-364-7700
  • Fax:
Mailing address:
  • Phone: 718-405-0765
  • Fax: 718-405-0765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number068148
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: