Healthcare Provider Details

I. General information

NPI: 1699392167
Provider Name (Legal Business Name): MIRANDA ANNE MAZZA-WRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 W EDGEWOOD AVE
INDIANAPOLIS IN
46217-9291
US

IV. Provider business mailing address

1502 W EDGEWOOD AVE
INDIANAPOLIS IN
46217-9291
US

V. Phone/Fax

Practice location:
  • Phone: 317-561-1888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number46004756A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: