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General NPI Number Information
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NPI Number | 1578289963
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Entity Type | Individual
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Provider Name | MIRANDA RENEE MESTAS VATTEROTT ASW
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Gender | Female
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Dates
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Enumeration Date | 10/17/2022
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Last Update Date | 10/19/2022
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Provider Practice Location Address
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Address Line | 8075 W 3RD ST
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City | LOS ANGELES
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State | CA
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Zip | 90048-4318
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Country | US
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Telephone | 424-587-5224
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Fax |
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Provider Business Mailing Address
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Address Line | 5120 MESMER AVE
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City | CULVER CITY
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State | CA
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Zip | 90230-6039
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Country | US
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Telephone | 310-503-4492
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | ASW87839
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License Number State | CA
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