1306203344 NPI number — MIRA MAHENDRA CAVANAUGH MA, LPC, ATR

Table of content: MIRA MAHENDRA CAVANAUGH MA, LPC, ATR (NPI 1306203344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306203344 NPI number — MIRA MAHENDRA CAVANAUGH MA, LPC, ATR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAVANAUGH
Provider First Name:
MIRA
Provider Middle Name:
MAHENDRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, ATR
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:
1306203344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13001 SW 63RD PL
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:
97219-8068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12578 SW BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97005-2136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-367-3268
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2016

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: 101YM0800X , with the licence number:  C3985 , 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)





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