Basic Information
| Provider Information | |||||||||
| NPI: | 1669801023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRANDA | ||||||||
| FirstName: | JOHNNY | ||||||||
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| Credential: | B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 NORMAN ST | ||||||||
| Address2: | |||||||||
| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010895003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137368329 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2155 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011043301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137360395 | ||||||||
| FaxNumber: | 4137341651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2013 | ||||||||
| LastUpdateDate: | 11/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 042622756 | 01 | MA | COMMONWEALTH CARE ALLIANCE | OTHER | 1307576 | 01 | MA | MBHP | OTHER | 12529 | 01 | MA | HEALTH NEW ENGLAND | OTHER | 1307576 | 05 | MA | MEDICAID | 8443 | 01 | MA | BMC | OTHER | 1022610 | 01 | MA | NHP | OTHER | 1022610 | 01 | MA | FALLON | OTHER | 997203 | 01 | MA | NETWORK HEALTH | OTHER | Y10086 | 01 | MA | MEDICARE | OTHER | 1022610 | 01 | MA | BEACON/BMC | OTHER | 71756 | 01 | MA | TUFTS | OTHER |