Provider Demographics
NPI:1922400647
Name:MIRANDETTE, BARBARA (PT)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:MIRANDETTE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 3 MILE RD NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8251
Mailing Address - Country:US
Mailing Address - Phone:616-785-8535
Mailing Address - Fax:616-785-1201
Practice Address - Street 1:1550 3 MILE RD NW
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8251
Practice Address - Country:US
Practice Address - Phone:616-785-8535
Practice Address - Fax:616-785-1201
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist