Provider Demographics
NPI:1255945440
Name:MARTIN, MIRANDA C (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:C
Last Name:MARTIN
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 1:831 CHERRY ST APT 33
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-4040
Mailing Address - Country:US
Mailing Address - Phone:630-452-6370
Mailing Address - Fax:
Practice Address - Street 1:7395 W EASTMAN PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-5006
Practice Address - Country:US
Practice Address - Phone:303-730-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist