Provider Demographics
NPI:1346802592
Name:FREDERICK, MIRANDA N (DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:N
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 N SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2059
Mailing Address - Country:US
Mailing Address - Phone:509-326-1651
Mailing Address - Fax:509-326-1658
Practice Address - Street 1:1016 N SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2059
Practice Address - Country:US
Practice Address - Phone:509-326-1651
Practice Address - Fax:509-326-1658
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60951895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist