Provider Demographics
NPI:1164718912
Name:DAVIS SIMONS, MIRANDA HEATHER (SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:HEATHER
Last Name:DAVIS SIMONS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:HEATHER
Other - Last Name:KISTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-273-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist