Provider Demographics
NPI:1710243712
Name:LISH, MIRANDA LYNN (OT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:LISH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:LYNN
Other - Last Name:GRUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:SHRINERS HOSPITALS FOR CHILDREN
Mailing Address - Street 2:PO BOX 8500, LOCKBOX #7642
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:1645 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-5007
Practice Address - Country:US
Practice Address - Phone:814-875-8700
Practice Address - Fax:814-875-8756
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012239225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist