=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366240459
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA RAE MIRANDA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2025
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1019 EGYPT RD UNIT 2B
-----------------------------------------------------
City | PHOENIXVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19460-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-214-5550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 862 E SCHUYLKILL RD APT 128
-----------------------------------------------------
City | POTTSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19465-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-552-6875
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SL016636
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------