Provider Demographics
NPI:1982043238
Name:CONDEE, MIRANDA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:CONDEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5187 US ROUTE 60
Mailing Address - Street 2:SUITE 28
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2076
Mailing Address - Country:US
Mailing Address - Phone:304-733-9430
Mailing Address - Fax:
Practice Address - Street 1:5187 US ROUTE 60
Practice Address - Street 2:SUITE 28
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2076
Practice Address - Country:US
Practice Address - Phone:304-733-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT002903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist