Provider Demographics
NPI:1245429927
Name:MARTIN, MIRANDA FILICITY (PT)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:FILICITY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1458
Mailing Address - Country:US
Mailing Address - Phone:313-594-1653
Mailing Address - Fax:313-594-9797
Practice Address - Street 1:3001 MILLER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1458
Practice Address - Country:US
Practice Address - Phone:313-594-1653
Practice Address - Fax:313-594-9797
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist