Provider Demographics
NPI:1922846625
Name:MARTIN, MIRANDA SHAY (COTA/L)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SHAY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 MAID MARION CT
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-6822
Mailing Address - Country:US
Mailing Address - Phone:606-922-0850
Mailing Address - Fax:
Practice Address - Street 1:5052 MAID MARION CT
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-6822
Practice Address - Country:US
Practice Address - Phone:606-922-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2389225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics