Provider Demographics
NPI:1972497014
Name:BURGETT, MIRANDA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BURGETT
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 1:6925 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-4089
Mailing Address - Country:US
Mailing Address - Phone:949-400-0113
Mailing Address - Fax:
Practice Address - Street 1:6925 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-4089
Practice Address - Country:US
Practice Address - Phone:949-400-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.029194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist