Basic Information
| Provider Information | |||||||||
| NPI: | 1437805850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | LEEANN | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1071 W BLUE STARR DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740172868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183414343 | ||||||||
| FaxNumber: | 9183418687 | ||||||||
| Practice Location | |||||||||
| Address1: | 1071 W BLUE STARR DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740172868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183414343 | ||||||||
| FaxNumber: | 9183418687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2022 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5637 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.