Provider Demographics
NPI:1720379886
Name:MIRAMONTES, SANDRA EMILCE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:EMILCE
Last Name:MIRAMONTES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10054 BYNUM CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-8276
Mailing Address - Country:US
Mailing Address - Phone:407-970-4782
Mailing Address - Fax:
Practice Address - Street 1:10054 BYNUM CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-8276
Practice Address - Country:US
Practice Address - Phone:407-970-4782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2025-03-14
Deactivation Date:2013-08-26
Deactivation Code:
Reactivation Date:2023-04-24
Provider Licenses
StateLicense IDTaxonomies
FLMT4558106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist