Provider Demographics
NPI:1902439300
Name:MIRANDA, PAUL (RADT-1)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 EL PORTAL DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-3143
Mailing Address - Country:US
Mailing Address - Phone:530-722-1114
Mailing Address - Fax:
Practice Address - Street 1:2532 WILSON AVE APT D
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1741
Practice Address - Country:US
Practice Address - Phone:530-524-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty