=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821640079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAITLIN MARIE MIRANDA PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2019
-----------------------------------------------------
Last Update Date | 07/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 E 2ND ST
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-4686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-766-8702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 HARRISON TER
-----------------------------------------------------
City | EAST QUOGUE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11942-4320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-747-5022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 29705
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 023050
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------