Provider Demographics
NPI:1710581988
Name:ROBERTS, MIRANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:ROBERTS
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 1:1400 FORDHAM DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5368
Mailing Address - Country:US
Mailing Address - Phone:757-361-3951
Mailing Address - Fax:757-361-3957
Practice Address - Street 1:1400 FORDHAM DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5368
Practice Address - Country:US
Practice Address - Phone:757-361-3951
Practice Address - Fax:757-361-3957
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213832225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist