Provider Demographics
NPI:1417227943
Name:MARTIN, MIRANDA L
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:L
Last Name:MARTIN
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 1:18621 E CHENANGO PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-3202
Mailing Address - Country:US
Mailing Address - Phone:720-323-1834
Mailing Address - Fax:
Practice Address - Street 1:18621 E CHENANGO PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-3202
Practice Address - Country:US
Practice Address - Phone:720-323-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT-7108225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist