Provider Demographics
NPI:1588286777
Name:MIRANDA, MIKAYLA (OTR/L)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 HALL ST
Mailing Address - Street 2:
Mailing Address - City:FEEDING HILLS
Mailing Address - State:MA
Mailing Address - Zip Code:01030-1926
Mailing Address - Country:US
Mailing Address - Phone:413-519-8772
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13528225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5419OtherDEPARTMENT OF PUBLIC HEALTH
MA13528OtherMASSACHUSETTS BOARD OF ALLIED HEALTH PROFESSIONALS