=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902439300
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL MIRANDA CADC-11
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2020
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 335 LAKE BLVD APT 11
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96003-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-524-8613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1147 HARTNELL AVE
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96002-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-222-7213
-----------------------------------------------------
Fax | 530-222-7268
-----------------------------------------------------
=====================================================
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 | A064370624
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------