Provider Demographics
NPI:1427275999
Name:MIRANDA, MARY A
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MIRANDA
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 1:1115 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5443
Mailing Address - Country:US
Mailing Address - Phone:573-392-8000
Mailing Address - Fax:573-392-8080
Practice Address - Street 1:1115 FAIRGROUNDS RD
Practice Address - Street 2:ELDON R-I AND SPECIAL LEARNING CENTER
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5443
Practice Address - Country:US
Practice Address - Phone:573-392-8000
Practice Address - Fax:573-392-8080
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002015973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO487457608Medicaid