Provider Demographics
NPI:1174789259
Name:MIRANDA, MARIA LUCIANO
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LUCIANO
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6361 BRAYBOURNE PL
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6563
Mailing Address - Country:US
Mailing Address - Phone:901-767-1040
Mailing Address - Fax:
Practice Address - Street 1:6361 BRAYBOURNE PL
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6563
Practice Address - Country:US
Practice Address - Phone:901-767-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist