Provider Demographics
NPI:1174106587
Name:MIRANDA, MAURICIO (MED, LPC)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 PARIS ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-5729
Mailing Address - Country:US
Mailing Address - Phone:956-898-0877
Mailing Address - Fax:
Practice Address - Street 1:2304 PARIS ST
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78574-5729
Practice Address - Country:US
Practice Address - Phone:956-898-0877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81610101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81610OtherLPC LICENSE