Provider Demographics
NPI:1073256079
Name:VALENZUELA, MYRANDA DEVYN (PTA)
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:DEVYN
Last Name:VALENZUELA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BROADWAY ST APT 2105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1345
Mailing Address - Country:US
Mailing Address - Phone:210-238-6413
Mailing Address - Fax:
Practice Address - Street 1:1800 BROADWAY ST APT 2015
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1298
Practice Address - Country:US
Practice Address - Phone:210-238-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2164918225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant