Provider Demographics
NPI:1306599402
Name:HURST, MIRANDA LEE (COTA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEE
Last Name:HURST
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:LEE
Other - Last Name:HURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MIRANDA MCNELLEY
Mailing Address - Street 1:2600 COMPASS RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8001
Mailing Address - Country:US
Mailing Address - Phone:877-787-3430
Mailing Address - Fax:
Practice Address - Street 1:2885 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4123
Practice Address - Country:US
Practice Address - Phone:636-614-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022001777224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant