Provider Demographics
NPI:1285868513
Name:MIRANDA, DENNIS BORJA (PT)
Entity type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:BORJA
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W KALSCHED ST
Mailing Address - Street 2:APT. 209
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1466
Mailing Address - Country:US
Mailing Address - Phone:715-383-0102
Mailing Address - Fax:
Practice Address - Street 1:311 W KALSCHED ST
Practice Address - Street 2:APT. 209
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1466
Practice Address - Country:US
Practice Address - Phone:715-383-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111340242251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics