Provider Demographics
NPI:1881364560
Name:WISELEY, MIRANDA SUE (COTA/L)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SUE
Last Name:WISELEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 S HIGHWAY 125
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-5123
Mailing Address - Country:US
Mailing Address - Phone:918-676-6884
Mailing Address - Fax:
Practice Address - Street 1:13300 S HIGHWAY 125
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-5123
Practice Address - Country:US
Practice Address - Phone:918-676-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2190224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant