Provider Demographics
NPI:1275999757
Name:WATSON, MIRANDA ROSE (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROSE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-4935
Mailing Address - Country:US
Mailing Address - Phone:816-348-1137
Mailing Address - Fax:
Practice Address - Street 1:110 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-4808
Practice Address - Country:US
Practice Address - Phone:816-348-1137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist