Provider Demographics
NPI:1538295001
Name:MASSIE, MIRANDA
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:MASSIE
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 1:21 W PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3754
Mailing Address - Country:US
Mailing Address - Phone:501-743-6460
Mailing Address - Fax:
Practice Address - Street 1:1500 WILSON LOOP
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176-8656
Practice Address - Country:US
Practice Address - Phone:501-588-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2077225X00000X
TNOT0000004364225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163340721Medicaid