Basic Information
| Provider Information | |||||||||
| NPI: | 1336382829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRANDA | ||||||||
| FirstName: | MARTA | ||||||||
| MiddleName: | GRACIELA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1141 PEAR TREE LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541770 | ||||||||
| FaxNumber: | 7072512993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1141 PEAR TREE LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541770 | ||||||||
| FaxNumber: | 7072512993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2009 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.