Provider Demographics
NPI:1891100061
Name:MIRANDA, BETH (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 N WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-2735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 N EMPORIA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3707
Practice Address - Country:US
Practice Address - Phone:316-858-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-00665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist