Provider Demographics
NPI:1316357056
Name:MAST, MIRANDA ARAGON (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ARAGON
Last Name:MAST
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13660 W ALASKA DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2420
Mailing Address - Country:US
Mailing Address - Phone:970-390-7745
Mailing Address - Fax:
Practice Address - Street 1:13660 W ALASKA DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2420
Practice Address - Country:US
Practice Address - Phone:970-390-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-03
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COSLP.0002090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16404033Medicaid