Basic Information
| Provider Information | |||||||||
| NPI: | 1629644984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRANDA LAMADRID | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | AUDELINA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12536 PENSKE ST | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519650617 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12968 FREDERICK ST STE A | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512427738 | ||||||||
| FaxNumber: | 9512080409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2021 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | APCC9172 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.