Provider Demographics
NPI:1497566624
Name:MIRISE, AMANDA KRISTAN (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KRISTAN
Last Name:MIRISE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E FERGUSON ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-5759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5759
Practice Address - Country:US
Practice Address - Phone:903-509-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14010882251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics