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General NPI Number Information
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NPI Number | 1992460430
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Entity Type | Organization
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Legal Business Name | MIRANDA MILLICAN MARRIAGE AND FAMILY THERAPIST INC
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Dates
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Enumeration Date | 10/31/2021
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Last Update Date | 10/31/2021
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Provider Practice Location Address
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Address Line | 3821 FRONT ST
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City | SAN DIEGO
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State | CA
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Zip | 92103-3019
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Country | US
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Telephone | 619-736-0495
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Fax |
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Provider Business Mailing Address
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Address Line | 3821 FRONT ST
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City | SAN DIEGO
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State | CA
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Zip | 92103-3019
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Country | US
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Telephone | 619-736-0495
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. MIRANDA ROSE ROTH MILLICAN
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Credential | LMFT
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Telephone | 619-736-0495
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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