Provider Demographics
NPI:1285349191
Name:VILA, MIRANDA N
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:N
Last Name:VILA
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 1:982 W BREVARD ST # 907
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32304-7709
Mailing Address - Country:US
Mailing Address - Phone:786-384-3477
Mailing Address - Fax:
Practice Address - Street 1:1909 HILLBROOKE TRL STE 3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-7902
Practice Address - Country:US
Practice Address - Phone:850-299-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-253909106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician