Provider Demographics
NPI:1790026599
Name:MILLER, MIRANDA RENEE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RENEE
Last Name:MILLER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:RENEE
Other - Last Name:HELLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 9578
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-9578
Mailing Address - Country:US
Mailing Address - Phone:530-543-5896
Mailing Address - Fax:530-544-6512
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-543-5896
Practice Address - Fax:530-544-6512
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17-0992225X00000X
CA16349225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist