Provider Demographics
NPI:1619323938
Name:GRIEBEL, MYRANDA L (PTA)
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:L
Last Name:GRIEBEL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MYRANDA
Other - Middle Name:
Other - Last Name:AXTELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:200 W DOUGLAS AVE STE 1040
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3017
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-0003
Practice Address - Street 1:3730 N RIDGE RD
Practice Address - Street 2:STE 500
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1227
Practice Address - Country:US
Practice Address - Phone:316-440-4901
Practice Address - Fax:316-440-4904
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1403028225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant