Basic Information
| Provider Information | |||||||||
| NPI: | 1104465590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTON | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MA SLP-CCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3855 WITHAM WOODS DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452452436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136590384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5640 COX SMITH RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450402210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133982881 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP.12862 | OH | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.