Provider Demographics
NPI:1285949164
Name:SAMPATH, MIRANDA W
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:W
Last Name:SAMPATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 SE 4TH AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-1900
Mailing Address - Country:US
Mailing Address - Phone:954-616-5088
Mailing Address - Fax:954-616-5147
Practice Address - Street 1:1421 SE 4TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1900
Practice Address - Country:US
Practice Address - Phone:954-616-5088
Practice Address - Fax:954-616-5147
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist