Provider Demographics
NPI:1053570366
Name:MIRANDA, GABRIELLE M (MS, MFT)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:M
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 SAN ANSELMO AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2621
Mailing Address - Country:US
Mailing Address - Phone:415-572-6455
Mailing Address - Fax:
Practice Address - Street 1:558 SAN ANSELMO AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2621
Practice Address - Country:US
Practice Address - Phone:415-572-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43146106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist