Provider Demographics
NPI:1003080664
Name:SHAH, MIRA E (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:E
Last Name:SHAH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 SE 61ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1320
Mailing Address - Country:US
Mailing Address - Phone:503-348-0931
Mailing Address - Fax:
Practice Address - Street 1:2855 SE 61ST AVENUE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1320
Practice Address - Country:US
Practice Address - Phone:503-348-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09121071OtherASHA
OR11905OtherSTATE LICENSE
WA4B3VBDX2W6CCB6CWCKMFOtherSTATE LICENSE