Provider Demographics
NPI:1326167677
Name:MCCORMACK, MIRANDA LYNN (OTR L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 W CENTRAL PARK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1631
Mailing Address - Country:US
Mailing Address - Phone:316-209-2277
Mailing Address - Fax:
Practice Address - Street 1:2114 N 127TH CT E
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3003
Practice Address - Country:US
Practice Address - Phone:316-500-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist