Healthcare Provider Details

I. General information

NPI: 1922815117
Provider Name (Legal Business Name): MIRANDA ALYSSE BOHEME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 W PALMETTO PARK RD STE 212
BOCA RATON FL
33486-3322
US

IV. Provider business mailing address

1499 W PALMETTO PARK RD STE 212
BOCA RATON FL
33486-3322
US

V. Phone/Fax

Practice location:
  • Phone: 561-479-8307
  • Fax:
Mailing address:
  • Phone: 561-494-4499
  • Fax: 561-705-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA23183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: