MEDICARE: MIRANDA COUNSELING & CONSULTING LICENSED CLINICAL SOCIAL WORKER, INC.

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184320095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRANDA COUNSELING & CONSULTING LICENSED CLINICAL SOCIAL WORKER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 8685
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92812-0685
Country	:	US
Telephone Number	:	760-509-2360
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 S EL CAMINO REAL STE 305
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6376
Country	:	US
Telephone Number	:	760-509-2360
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER/CEO
Name	:	MAYOLA MIRANDA
Credential	:	LCSW
Telephone Number	:	760-509-2360

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	06/29/2023

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