MEDICARE: MARILYNN MIRANDA PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	3262	PR

General Provider Information

NPI Number	:	1124543673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYNN MIRANDA PH.D

Provider Business Mailing Address
First Line	:	10 RES HATO GRANDE APT 51
Second Line	:
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-4110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 CALLE VICTORIA
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00912-3123
Country	:	US
Telephone Number	:	787-722-9595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2017
Last Update Date	:	08/06/2017

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