Provider Demographics
NPI:1659909950
Name:KOESTERER, MIRANDA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KOESTERER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:PAULUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2340 PARKLAND BLVD APT 15
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7369
Mailing Address - Country:US
Mailing Address - Phone:567-644-5678
Mailing Address - Fax:
Practice Address - Street 1:844 CAMBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1976
Practice Address - Country:US
Practice Address - Phone:618-624-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020009519225X00000X
IL056.013548225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist