Healthcare Provider Details

I. General information

NPI: 1790365096
Provider Name (Legal Business Name): SAVANNAH N MIRANDA MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAVANNAH N CHAVEZ

II. Dates (important events)

Enumeration Date: 04/11/2021
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 ATRISCO DR NW
ALBUQUERQUE NM
87120-4980
US

IV. Provider business mailing address

8116 SAN FRANCISCO RD NE
ALBUQUERQUE NM
87109-4904
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-1830
  • Fax:
Mailing address:
  • Phone: 505-697-8332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT4442
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: