Provider Demographics
NPI:1508328592
Name:SUMMERS, MIRANDA RENEE (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENEE
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 WYNBURNE AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1703
Mailing Address - Country:US
Mailing Address - Phone:724-854-0203
Mailing Address - Fax:
Practice Address - Street 1:4602 WYNBURNE AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1703
Practice Address - Country:US
Practice Address - Phone:724-854-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022888-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist