Provider Demographics
NPI:1689365298
Name:REYNA, MIRANDA TERESA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:TERESA
Last Name:REYNA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 TRAVIS AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3186
Mailing Address - Country:US
Mailing Address - Phone:512-626-2256
Mailing Address - Fax:
Practice Address - Street 1:2817 W BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-2303
Practice Address - Country:US
Practice Address - Phone:682-348-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225100000X
TX1376246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist