Provider Demographics
NPI:1144578204
Name:PALMER, MIRANDA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:PALMER
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20206 OREGON TRL
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1132
Mailing Address - Country:US
Mailing Address - Phone:708-679-9006
Mailing Address - Fax:888-851-4221
Practice Address - Street 1:20206 OREGON TRL
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1132
Practice Address - Country:US
Practice Address - Phone:708-679-9006
Practice Address - Fax:888-851-4221
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009367225X00000X
IN225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist