Provider Demographics
NPI:1780258947
Name:WALTERS, MYRANDA NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:NICOLE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8767 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JASONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47438-7038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E OHIO ST
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-1607
Practice Address - Country:US
Practice Address - Phone:812-665-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist