Provider Demographics
NPI:1700586005
Name:CHAVEZ, MIRANDA RAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RAE
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 CAPSTONE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-3616
Mailing Address - Country:US
Mailing Address - Phone:830-623-0116
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PKWY STE 260
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-1796
Practice Address - Country:US
Practice Address - Phone:737-237-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1372455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist