Basic Information
| Provider Information | |||||||||
| NPI: | 1326662727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGESON | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4023 W 234TH PL | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905054617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149164940 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10929 SOUTH ST STE 208B | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907035391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628656444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2020 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 103760 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.