Provider Demographics
NPI:1801543400
Name:SIBERT, MIRANDA RAE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RAE
Last Name:SIBERT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:RAE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3511 13TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-5301
Mailing Address - Country:US
Mailing Address - Phone:765-585-7493
Mailing Address - Fax:
Practice Address - Street 1:3511 13TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-5301
Practice Address - Country:US
Practice Address - Phone:765-585-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA18773235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist