Basic Information
| Provider Information | |||||||||
| NPI: | 1174546220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRANDA | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018708 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MEDICAL PLZ | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/15/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY 10158 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | PSY101580 | 05 | CA | MEDICAID | 00PSY10158 | 01 | CA | BLUE SHIELD | OTHER |