Provider Demographics
NPI:1841289816
Name:AUSTIN, MIRANDA KATHLEEN (MPT)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:KATHLEEN
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POLE LINE RD W STE 202
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5820
Mailing Address - Country:US
Mailing Address - Phone:208-814-2570
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 202
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5820
Practice Address - Country:US
Practice Address - Phone:208-814-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29616225100000X
IDPT-24582251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist