Provider Demographics
NPI:1154148773
Name:MIRANDA, MADISON ANNE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ANNE
Last Name:MIRANDA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 W COBALT DR UNIT B113
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5813
Mailing Address - Country:US
Mailing Address - Phone:208-841-3389
Mailing Address - Fax:
Practice Address - Street 1:2940 W COBALT DR UNIT B113
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5813
Practice Address - Country:US
Practice Address - Phone:208-841-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist