Provider Demographics
NPI:1083267793
Name:ROBLES, MIRANDA (DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:ROBLES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:CELELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1200 GOLFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-6620
Mailing Address - Country:US
Mailing Address - Phone:111-111-1111
Mailing Address - Fax:
Practice Address - Street 1:970 FORT WAYNE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4328
Practice Address - Country:US
Practice Address - Phone:906-282-8314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IN05013533A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist