Provider Demographics
NPI:1043975410
Name:REEVERTS, MIRANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:REEVERTS
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 1:212A DALE HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-6106
Mailing Address - Country:US
Mailing Address - Phone:812-774-2538
Mailing Address - Fax:
Practice Address - Street 1:212A DALE HAVEN DR
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-6106
Practice Address - Country:US
Practice Address - Phone:812-774-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014243A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty