Provider Demographics
NPI:1629416953
Name:MICHAUD, MIRANDA A (LMT)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:A
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HILLTOP RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-5108
Mailing Address - Country:US
Mailing Address - Phone:860-748-6293
Mailing Address - Fax:
Practice Address - Street 1:111 LOOMIS RD
Practice Address - Street 2:C/O FIVE ELEMENTS HEALING CENTER
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-2330
Practice Address - Country:US
Practice Address - Phone:860-748-6293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-09
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7410225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist