Provider Demographics
NPI:1194839993
Name:MERRIMAN, MIRA BETH (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:BETH
Last Name:MERRIMAN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 CEDAR LAKE RD S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3700
Mailing Address - Country:US
Mailing Address - Phone:952-381-3434
Mailing Address - Fax:952-377-1430
Practice Address - Street 1:4330 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3700
Practice Address - Country:US
Practice Address - Phone:952-381-3434
Practice Address - Fax:952-377-1430
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5807235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP65441OtherHEALTH PARTNERS