=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104479930
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A MIRANDA LPC, LCDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2019
-----------------------------------------------------
Last Update Date | 04/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E HOUSTON ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78205-2990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-414-4327
-----------------------------------------------------
Fax | 210-451-0492
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 ENCANTA ST APT 402
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-6459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 726-300-4948
-----------------------------------------------------
Fax | 210-451-0492
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 115868
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | 115868
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------