Provider Demographics
NPI:1366408064
Name:VALLOR, MIRANDA BETH (PT)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:BETH
Last Name:VALLOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MIRANDA
Other - Middle Name:BETH
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:584 BALD MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04429
Mailing Address - Country:US
Mailing Address - Phone:207-843-6051
Mailing Address - Fax:207-667-0288
Practice Address - Street 1:125 OAK ST
Practice Address - Street 2:STE 2
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-667-0290
Practice Address - Fax:207-667-0288
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
206513Medicare ID - Type Unspecified