Provider Demographics
NPI:1942321062
Name:MIRANDA, FABIOLA
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10328 BROOKMEAD DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-2613
Mailing Address - Country:US
Mailing Address - Phone:951-485-4749
Mailing Address - Fax:
Practice Address - Street 1:6355 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3163
Practice Address - Country:US
Practice Address - Phone:951-369-5714
Practice Address - Fax:951-686-9559
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health