Provider Demographics
NPI:1932569589
Name:MCCOY, MIRANDA LEE (PT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:LEE
Other - Last Name:YEAGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 W UNIVERSITY AVE STE 335
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-5343
Practice Address - Country:US
Practice Address - Phone:630-296-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1272142225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist