=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376948943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRANDA COMMUNICATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2014
-----------------------------------------------------
Last Update Date | 10/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5205 ORDSALL PL VA BEACH, VA
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-6884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-378-0253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5205 ORDSALL PL VA BEACH, VA
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-6884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-378-0253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR SOCIAL WORK
-----------------------------------------------------
Name | MS. EDITH BEAN BEAUJON
-----------------------------------------------------
Credential | L.C.S.W
-----------------------------------------------------
Telephone | 917-378-0253
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904008451
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------