Provider Demographics
NPI:1306190657
Name:MAYRA M MIRO, INC.
Entity Type:Organization
Organization Name:MAYRA M MIRO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MIRO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-807-9119
Mailing Address - Street 1:11401 SW 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3372
Mailing Address - Country:US
Mailing Address - Phone:305-807-9119
Mailing Address - Fax:305-445-9045
Practice Address - Street 1:11401 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3372
Practice Address - Country:US
Practice Address - Phone:305-807-9119
Practice Address - Fax:305-445-9045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty