Provider Demographics
NPI:1235825647
Name:MARTIN, MIRANDA ELLEN
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ELLEN
Last Name:MARTIN
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 1:3800 DALECREST DR UNIT 1061
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-1795
Mailing Address - Country:US
Mailing Address - Phone:715-587-2381
Mailing Address - Fax:
Practice Address - Street 1:3800 DALECREST DR UNIT 1061
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-1795
Practice Address - Country:US
Practice Address - Phone:715-587-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist