Provider Demographics
NPI:1285994939
Name:MIRANDA, DANIEL BOONE
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:BOONE
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1989 VICENTE DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6863
Mailing Address - Country:US
Mailing Address - Phone:805-781-4179
Mailing Address - Fax:
Practice Address - Street 1:1989 VICENTE DR
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6863
Practice Address - Country:US
Practice Address - Phone:805-781-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36369101YM0800X
CA36369167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health