Provider Demographics
NPI:1639823339
Name:MIRANDA, KASEY ANNE (PTA)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:ANNE
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-8001
Mailing Address - Country:US
Mailing Address - Phone:205-902-9431
Mailing Address - Fax:
Practice Address - Street 1:600 E GARFIELD ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-2034
Practice Address - Country:US
Practice Address - Phone:620-365-3183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03957225200000X
ALPTA9427225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALEDU837505499OtherBCBS PEEHIP