Provider Demographics
NPI:1093084857
Name:GENSLER, MIRANDA (DAOM, LAC,)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:GENSLER
Suffix:
Gender:F
Credentials:DAOM, LAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MOTT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062
Mailing Address - Country:US
Mailing Address - Phone:503-740-4772
Mailing Address - Fax:509-588-7072
Practice Address - Street 1:2840 PARK AVE
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2866
Practice Address - Country:US
Practice Address - Phone:831-515-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14879171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist