Provider Demographics
NPI:1215582119
Name:OTTE, MIRANDA SKYE (OT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SKYE
Last Name:OTTE
Suffix:
Gender:F
Credentials:OT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-4925
Mailing Address - Country:US
Mailing Address - Phone:620-218-9576
Mailing Address - Fax:
Practice Address - Street 1:1855 S ROCK RD STE 155
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5113
Practice Address - Country:US
Practice Address - Phone:316-682-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT76172255A2300X
KS17-04263225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer