Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT4564 | GA |
N | 2251P0200X | Physical Therapist - Pediatrics | PT004564 | GA |
N | 2251S0007X | Physical Therapist - Sports | ||
N | 2251X0800X | Physical Therapist - Orthopedic | ||
N | 225700000X | Massage Therapist |
NPI | 1386744233 |
---|---|
Provider Name | Prof. Miranda White |
First Address | Mableton, GA 30126 |
Second Address | Atlanta, GA 30336-1533 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 30/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
618882941A | (05) | GA |