Provider Demographics
NPI:1861963225
Name:RADCLIFF, MIRANDA (PTA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:RADCLIFF
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:MORRAL
Mailing Address - State:OH
Mailing Address - Zip Code:43337-9311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 GOLDEN HILL DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-6442
Practice Address - Country:US
Practice Address - Phone:845-340-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011569-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant