Provider Demographics
NPI:1912673898
Name:SEREDA, MIRANDA (DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SEREDA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:9069 W OLIVE AVE STE 105
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-9124
Practice Address - Country:US
Practice Address - Phone:623-257-2079
Practice Address - Fax:623-257-2706
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZLPT-31898225200000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant