Healthcare Provider Details

I. General information

NPI: 1073838660
Provider Name (Legal Business Name): JUANA MIRANDA-LOPEZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 W 86TH ST
NEW YORK NY
10024-4018
US

IV. Provider business mailing address

228 E ROUTE 59 # 400
NANUET NY
10954-2905
US

V. Phone/Fax

Practice location:
  • Phone: 212-362-8755
  • Fax:
Mailing address:
  • Phone: 718-280-5436
  • Fax: 718-414-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC05896100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104100000X
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: