Basic Information
| Provider Information | |||||||||
| NPI: | 1720259781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELIZONDO | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | MARTINEZ | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 N MAIN AVE STE 740 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782125711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102717411 | ||||||||
| FaxNumber: | 2102719411 | ||||||||
| Practice Location | |||||||||
| Address1: | 8527 BRAUN KNL | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782545584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105219469 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 62118 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.