Provider Demographics
NPI:1972379550
Name:BIRMINGHAM, MARANDA (PT,DPT)
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:
Last Name:BIRMINGHAM
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 BUCKEYE ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-1151
Mailing Address - Country:US
Mailing Address - Phone:219-286-5798
Mailing Address - Fax:
Practice Address - Street 1:777 S MAIN ST STE 500
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-3000
Practice Address - Country:US
Practice Address - Phone:765-832-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05015392A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy