Basic Information
| Provider Information | |||||||||
| NPI: | 1922182542 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.S.O.T. R/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2959 SHARPSBURG MCCULLUM RD | ||||||||
| Address2: | BUILDING C, SUITE C | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302652297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706830250 | ||||||||
| FaxNumber: | 7706834250 | ||||||||
| Practice Location | |||||||||
| Address1: | 2959 SHARPSBURG MCCULLUM RD | ||||||||
| Address2: | BUILDING C, SUITE C | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302652297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706830250 | ||||||||
| FaxNumber: | 7706834250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT004286 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 109991859B | 05 | GA | MEDICAID |