Provider Demographics
NPI:1437849668
Name:STUTESMAN, MIRANDA (SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:STUTESMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 KYLEE CT
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-4407
Mailing Address - Country:US
Mailing Address - Phone:770-846-8041
Mailing Address - Fax:
Practice Address - Street 1:135 KYLEE CT
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-4407
Practice Address - Country:US
Practice Address - Phone:770-846-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009976235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist