Provider Demographics
NPI:1790359776
Name:ZIMMERMAN, MIRANDA LYNN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LYNN
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 WILLOW CHASE BLVD APT 1033
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-6806
Mailing Address - Country:US
Mailing Address - Phone:248-660-4598
Mailing Address - Fax:
Practice Address - Street 1:13082 CENTERFIELD DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:281-737-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT82162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9101003777OtherBLUE CROSS BLUE SHEILD