Provider Demographics
NPI:1083088355
Name:STAUFFER, MIRANDA (PTA)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:
Last Name:STAUFFER
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 1:1218 FUSELAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-4613
Mailing Address - Country:US
Mailing Address - Phone:240-682-6406
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 7
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-2114
Practice Address - Country:US
Practice Address - Phone:410-650-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4336225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant