MEDICARE: MR. TIMOTHY MIRANDA

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1386013621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY MIRANDA

Provider Business Mailing Address
First Line	:	2730 SHADELANDS DR BLDG 10
Second Line	:
City	:	WALNUT CREEK
State	:	CA
Zip	:	94598-2538
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	744 EMPIRE ST STE 160
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5562
Country	:	US
Telephone Number	:	707-399-9413
Fax Number	:

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

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	10/30/2019

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Directions to “ MR. TIMOTHY MIRANDA ” Practice Location

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