Provider Demographics
NPI:1669833869
Name:MIRANDA, KIMBERLEY (MSPT, MBA)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:MSPT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-6705
Mailing Address - Country:US
Mailing Address - Phone:718-566-8277
Mailing Address - Fax:718-566-8279
Practice Address - Street 1:99 MOORE ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-3329
Practice Address - Country:US
Practice Address - Phone:718-387-0555
Practice Address - Fax:718-387-0033
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY262047570OtherTIN NUMBER