Provider Demographics
NPI:1659103422
Name:MUNOZ, MYRANDA PAIGE
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:PAIGE
Last Name:MUNOZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-2323
Mailing Address - Country:US
Mailing Address - Phone:401-489-0787
Mailing Address - Fax:
Practice Address - Street 1:6 BLACKSTONE VALLEY PL STE 306A
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1112
Practice Address - Country:US
Practice Address - Phone:401-443-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP01734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty