Provider Demographics
NPI:1639702780
Name:SHIELDS, MIRANDA (LMT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SHIELDS
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 1:1001 W. OAK ST. BLDG C STE 210
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-587-8446
Mailing Address - Fax:406-587-0898
Practice Address - Street 1:1001 W. OAK ST. BLDG C STE 210
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-587-8446
Practice Address - Fax:406-587-0898
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-11981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTLMT-LMT-LIC-11981OtherMASSAGE THERAPIST LICENSE