Provider Demographics
NPI:1508161340
Name:MIRANDA, KINGA (OTR/L)
Entity Type:Individual
Prefix:
First Name:KINGA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 TUMBLEWEED DR
Mailing Address - Street 2:
Mailing Address - City:MOHAVE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86440-8945
Mailing Address - Country:US
Mailing Address - Phone:928-770-5026
Mailing Address - Fax:
Practice Address - Street 1:2812 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8309
Practice Address - Country:US
Practice Address - Phone:928-763-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3538225X00000X
NV10-0070225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist