Provider Demographics
NPI:1528520814
Name:MIRANDA, TANIA GRIJALVA
Entity type:Individual
Prefix:MISS
First Name:TANIA
Middle Name:GRIJALVA
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 1:1274 S PEARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1143
Mailing Address - Country:US
Mailing Address - Phone:559-991-6578
Mailing Address - Fax:
Practice Address - Street 1:4910 E. ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-256-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician