Healthcare Provider Details

I. General information

NPI: 1023558806
Provider Name (Legal Business Name): MIRANDA SHOWALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 DEER RUN RD
DANVILLE VA
24540-2863
US

IV. Provider business mailing address

175 DEER RUN RD
DANVILLE VA
24540-2863
US

V. Phone/Fax

Practice location:
  • Phone: 434-797-5531
  • Fax:
Mailing address:
  • Phone: 434-797-5531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119007251
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: