Provider Demographics
NPI:1609694108
Name:KNICKERBOCKER, MIRANDA JANE (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:MIRANDA
Middle Name:JANE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 NYS RTE 13
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3528
Mailing Address - Country:US
Mailing Address - Phone:607-753-9375
Mailing Address - Fax:607-758-9287
Practice Address - Street 1:882 NYS RTE 13
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-3528
Practice Address - Country:US
Practice Address - Phone:607-753-9375
Practice Address - Fax:607-758-9287
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029377225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist