=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588580716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDALIA MONTANEZ MIRANDA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2026
-----------------------------------------------------
Last Update Date | 06/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 SHIPYARD WAY UNIT 1107
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-505-7210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 126
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32085-0126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-505-7210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. IDALIA MONTANEZ-MIRANDA
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 805-505-7210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------