Provider Demographics
NPI:1306303722
Name:WAITE, MIRANDA (COTA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:WAITE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 OAK ST
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9117
Mailing Address - Country:US
Mailing Address - Phone:440-488-8570
Mailing Address - Fax:
Practice Address - Street 1:402 GOLFVIEW LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-4414
Practice Address - Country:US
Practice Address - Phone:440-443-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007479224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant