Provider Demographics
NPI:1962229468
Name:FERNANDES DE MIRANDA SOARES, JULIA
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:FERNANDES DE MIRANDA SOARES
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 STONECREST DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-0226
Mailing Address - Country:US
Mailing Address - Phone:901-453-0322
Mailing Address - Fax:
Practice Address - Street 1:4075 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-7400
Practice Address - Country:US
Practice Address - Phone:901-584-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24374158106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician