Provider Demographics
NPI:1497287874
Name:STAUCH, MYRANDA
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
Last Name:STAUCH
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 1:2901 STADIUM DRIVE
Mailing Address - Street 2:TCU BOX 290315
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76129
Mailing Address - Country:US
Mailing Address - Phone:210-279-1581
Mailing Address - Fax:
Practice Address - Street 1:2901 STADIUM DRIVE
Practice Address - Street 2:TCU BOX 290315
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76129
Practice Address - Country:US
Practice Address - Phone:210-279-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer