Provider Demographics
NPI:1346912763
Name:IVERS, MIRANDA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:IVERS
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-3877
Mailing Address - Country:US
Mailing Address - Phone:605-695-6881
Mailing Address - Fax:
Practice Address - Street 1:930 12TH ST S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-3877
Practice Address - Country:US
Practice Address - Phone:605-695-6881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NMOT4562225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist