Provider Demographics
NPI:1902592470
Name:MIRANDA-GONZALEZ, JOSUE
Entity Type:Individual
Prefix:
First Name:JOSUE
Middle Name:
Last Name:MIRANDA-GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 DONNEGAL AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 S 35TH ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053-9688
Practice Address - Country:US
Practice Address - Phone:269-250-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician