Provider Demographics
NPI:1306203344
Name:CAVANAUGH, MIRA MAHENDRA (MA, LPC, ATR)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:MAHENDRA
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MA, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13001 SW 63RD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-8068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12578 SW BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2136
Practice Address - Country:US
Practice Address - Phone:503-367-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3985101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health