Provider Demographics
NPI:1750916243
Name:WILLIAMS, MIRANDA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:WILLIAMS
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 1:2011 DEERFIELD CMNS
Mailing Address - Street 2:
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-8541
Mailing Address - Country:US
Mailing Address - Phone:717-681-8331
Mailing Address - Fax:866-312-8121
Practice Address - Street 1:2011 DEERFIELD CMNS
Practice Address - Street 2:
Practice Address - City:SHIPPENSBURG
Practice Address - State:PA
Practice Address - Zip Code:17257-8541
Practice Address - Country:US
Practice Address - Phone:717-681-8331
Practice Address - Fax:866-312-8121
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist