Provider Demographics
NPI:1720680507
Name:NEW, MIRANDA LEE (PT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LEE
Last Name:NEW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 RABBIT RD
Mailing Address - Street 2:
Mailing Address - City:SABATTUS
Mailing Address - State:ME
Mailing Address - Zip Code:04280-4951
Mailing Address - Country:US
Mailing Address - Phone:207-890-4792
Mailing Address - Fax:
Practice Address - Street 1:15 STRAWBERRY AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5941
Practice Address - Country:US
Practice Address - Phone:207-777-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist