MEDICARE: PROF. MIRANDA WHITE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	PT004564	GA
2	2251S0007X	Sports Physical Therapist
3	2251X0800X	Orthopedic Physical Therapist
4	225700000X	Massage Therapist
5	225100000X	Physical Therapist	PT4564	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386744233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. MIRANDA WHITE DPT

Provider Business Mailing Address
First Line	:	1228 WANDERING VINE CT. SE
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126
Country	:	US
Telephone Number	:	678-685-1386
Fax Number	:	678-601-1341

Provider Business Practice Location Address
First Line	:	1311A FULTON INDUSTRIAL BLVD NW STE 5
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30336-1533
Country	:	US
Telephone Number	:	678-685-1386
Fax Number	:	678-601-1341

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	01/30/2020

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Directions to “ PROF. MIRANDA WHITE DPT” Practice Location

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