Provider Demographics
NPI:1790230290
Name:ROSEN, MIRANDA JANE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:JANE
Last Name:ROSEN
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 1:5852 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3719
Mailing Address - Country:US
Mailing Address - Phone:714-609-4004
Mailing Address - Fax:
Practice Address - Street 1:6930 WARNER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5316
Practice Address - Country:US
Practice Address - Phone:714-847-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist