Provider Demographics
NPI:1194386482
Name:MIRANDA, MICHELE KATHLEEN
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:KATHLEEN
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 TOWNE PARK DR W APT 527
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-4117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 TOWNE PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5153
Practice Address - Country:US
Practice Address - Phone:912-826-5450
Practice Address - Fax:912-826-6413
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007331225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist