Healthcare Provider Details

I. General information

NPI: 1982043238
Provider Name (Legal Business Name): MIRANDA CONDEE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRANDA ELLIS PT

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5187 US ROUTE 60 SUITE 28
HUNTINGTON WV
25705-2076
US

IV. Provider business mailing address

5187 US ROUTE 60 SUITE 28
HUNTINGTON WV
25705-2076
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-9430
  • Fax:
Mailing address:
  • Phone: 304-733-9430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002903
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: