Provider Demographics
NPI:1528715976
Name:MIRANDA, JOANNA MARIE
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:MARIE
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 1:8036 PEACEFUL WOODS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-5195
Mailing Address - Country:US
Mailing Address - Phone:725-666-3541
Mailing Address - Fax:
Practice Address - Street 1:7125 GRAND MONTECITO PKWY STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-0261
Practice Address - Country:US
Practice Address - Phone:702-396-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-21-196764106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician