Healthcare Provider Details

I. General information

NPI: 1467245985
Provider Name (Legal Business Name): MIA VENEGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3592 S ATHERTON BLVD STE 110
GILBERT AZ
85297-7444
US

IV. Provider business mailing address

426 E MILLETT AVE
MESA AZ
85204-4125
US

V. Phone/Fax

Practice location:
  • Phone: 480-840-6777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-033747
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: