MEDICARE: DR. ROBERTA ANGELA MIRANDA LADC, CPC, NCC, ACS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LADC #1160	NV
2	101YP2500X	Professional Counselor	NCC#204921	NV
3	101YP2500X	Professional Counselor	CPC#0049	NV

General Provider Information

NPI Number	:	1679817043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERTA ANGELA MIRANDA LADC, CPC, NCC, ACS

Provider Business Mailing Address
First Line	:	2000 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-4100
Country	:	US
Telephone Number	:	702-204-3609
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-4100
Country	:	US
Telephone Number	:	702-204-3609
Fax Number	:

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

Provider Enumeration Date	:	11/24/2012
Last Update Date	:	02/07/2023

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