Provider Demographics
NPI:1366025397
Name:MIRANDA, ANTONELLA STEPHANIE
Entity type:Individual
Prefix:
First Name:ANTONELLA
Middle Name:STEPHANIE
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 1:6538 NETHERSEAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-5352
Mailing Address - Country:US
Mailing Address - Phone:702-338-0120
Mailing Address - Fax:
Practice Address - Street 1:6538 NETHERSEAL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-5352
Practice Address - Country:US
Practice Address - Phone:702-338-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician