1003080664 NPI number — MIRA E SHAH M.S. CCC-SLP

Table of content: MIRA E SHAH M.S. CCC-SLP (NPI 1003080664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003080664 NPI number — MIRA E SHAH M.S. CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
MIRA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S. CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003080664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2855 SE 61ST AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97206-1320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-348-0931
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2855 SE 61ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97206-1320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-348-0931
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  11905 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09121071 . This is a "ASHA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11905 . This is a "STATE LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 4B3VBDX2W6CCB6CWCKMF . This is a "STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".