Provider Demographics
NPI:1982904983
Name:PAINE-JESAM, MIRANDA IRENE (MT-BC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:IRENE
Last Name:PAINE-JESAM
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21236 ORME ST
Mailing Address - Street 2:
Mailing Address - City:ABITA SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70420-3430
Mailing Address - Country:US
Mailing Address - Phone:972-762-3403
Mailing Address - Fax:
Practice Address - Street 1:21236 ORME ST
Practice Address - Street 2:
Practice Address - City:ABITA SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70420-3430
Practice Address - Country:US
Practice Address - Phone:972-762-3403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09424225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist