Provider Demographics
NPI:1205471992
Name:TYLER, MIRANDA MAE (LMT)
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:MAE
Last Name:TYLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22323 OLD GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:SMITHSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21783-2949
Mailing Address - Country:US
Mailing Address - Phone:301-730-8575
Mailing Address - Fax:
Practice Address - Street 1:22323 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:SMITHSBURG
Practice Address - State:MD
Practice Address - Zip Code:21783-1607
Practice Address - Country:US
Practice Address - Phone:301-730-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06501225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist