Provider Demographics
NPI:1184320095
Name:MIRANDA COUNSELING & CONSULTING LICENSED CLINICAL SOCIAL WORKER, INC.
Entity type:Organization
Organization Name:MIRANDA COUNSELING & CONSULTING LICENSED CLINICAL SOCIAL WORKER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAYOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:760-509-2360
Mailing Address - Street 1:PO BOX 8685
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92812-0685
Mailing Address - Country:US
Mailing Address - Phone:760-509-2360
Mailing Address - Fax:
Practice Address - Street 1:2204 S EL CAMINO REAL STE 305
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6376
Practice Address - Country:US
Practice Address - Phone:760-509-2360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-02
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB344989Medicaid