Provider Demographics
NPI:1386744233
Name:WHITE, MIRANDA (DPT)
Entity type:Individual
Prefix:PROF
First Name:MIRANDA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 WANDERING VINE CT. SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:678-685-1386
Mailing Address - Fax:678-601-1341
Practice Address - Street 1:1311A FULTON INDUSTRIAL BLVD NW STE 5
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30336-1533
Practice Address - Country:US
Practice Address - Phone:678-685-1386
Practice Address - Fax:678-601-1341
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0045642251P0200X
2251S0007X, 2251X0800X, 225700000X
GAPT4564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA618882941AMedicaid