Provider Demographics
NPI:1871240366
Name:TERRY, MIRANDA (LMT, CNMT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:LMT, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4034 MALLETTE HTS UNIT 101
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-4524
Mailing Address - Country:US
Mailing Address - Phone:502-802-9166
Mailing Address - Fax:
Practice Address - Street 1:2120 ACADEMY CIR STE F
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1674
Practice Address - Country:US
Practice Address - Phone:502-802-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0024735225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty