Healthcare Provider Details

I. General information

NPI: 1144939521
Provider Name (Legal Business Name): MIRANDA GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CELEBRATION PL
KISSIMMEE FL
34747-4970
US

IV. Provider business mailing address

PO BOX 120547
CLERMONT FL
34712-0547
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT23695
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: