Healthcare Provider Details

I. General information

NPI: 1982187340
Provider Name (Legal Business Name): MARJORIE G MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 BEACH ST # 1
STATEN ISLAND NY
10304-2235
US

IV. Provider business mailing address

358 SAINT MARKS PL
STATEN ISLAND NY
10301-2417
US

V. Phone/Fax

Practice location:
  • Phone: 347-520-2077
  • Fax: 347-520-2077
Mailing address:
  • Phone: 646-942-7897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number138191
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: