Provider Demographics
NPI:1669939419
Name:SMALL, MIRANDA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W SERGEANT COURT DR STE 204
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-5809
Mailing Address - Country:US
Mailing Address - Phone:801-987-6733
Mailing Address - Fax:
Practice Address - Street 1:24 W SERGEANT COURT DR STE 204
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-5809
Practice Address - Country:US
Practice Address - Phone:801-987-6733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111437235Z00000X
UT11660935-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist