Healthcare Provider Details

I. General information

NPI: 1578244059
Provider Name (Legal Business Name): MIRANDA WADDLE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 11/24/2023
Certification Date: 11/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 E 3RD ST
LOS ANGELES CA
90013-1629
US

IV. Provider business mailing address

1041 PALM AVE
SAN GABRIEL CA
91776-3012
US

V. Phone/Fax

Practice location:
  • Phone: 213-620-5712
  • Fax:
Mailing address:
  • Phone: 915-249-5184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number25256
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: