Provider Demographics
NPI:1194338129
Name:DAVID J. MIRANDA, LCSW, PLLC
Entity type:Organization
Organization Name:DAVID J. MIRANDA, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:845-200-1101
Mailing Address - Street 1:76 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-1824
Mailing Address - Country:US
Mailing Address - Phone:845-200-1101
Mailing Address - Fax:
Practice Address - Street 1:720 ROUTE 17M
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4346
Practice Address - Country:US
Practice Address - Phone:845-320-2330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty