Provider Demographics
NPI:1285121616
Name:MIRANDA, YASMIN
Entity type:Individual
Prefix:
First Name:YASMIN
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 1:235 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1560
Mailing Address - Country:US
Mailing Address - Phone:484-654-9900
Mailing Address - Fax:
Practice Address - Street 1:235 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1560
Practice Address - Country:US
Practice Address - Phone:484-654-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14584101YA0400X
MDLC14902101YP2500X
PAPC016994324500000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility