Provider Demographics
NPI:1336683374
Name:OSWALD, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:OSWALD
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 1:225 E CENTER ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1456
Mailing Address - Country:US
Mailing Address - Phone:989-388-3534
Mailing Address - Fax:
Practice Address - Street 1:225 E CENTER ST UNIT B
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1456
Practice Address - Country:US
Practice Address - Phone:989-388-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5201010959225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician