Provider Demographics
NPI:1831690718
Name:MONCADA-SULLIVAN, MIRANDA (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MONCADA-SULLIVAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 BLUE SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9259
Mailing Address - Country:US
Mailing Address - Phone:989-249-3915
Mailing Address - Fax:
Practice Address - Street 1:3946 BLUE SPRUCE DR
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-9259
Practice Address - Country:US
Practice Address - Phone:989-249-3915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI5501016790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist