Provider Demographics
NPI:1215703004
Name:REZA, MIRANDA
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:
Last Name:REZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PREFERRED
Mailing Address - Street 1:2116 S ALMA ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1612
Practice Address - Country:US
Practice Address - Phone:714-879-4274
Practice Address - Fax:714-879-2274
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician