=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245509686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYANN MIRANDA LCADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2011
-----------------------------------------------------
Last Update Date | 12/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 192 3RD AVE
-----------------------------------------------------
City | WESTWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-2154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-220-3833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 A VE E
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-220-3833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 37LC00165400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------