Provider Demographics
NPI:1396231015
Name:MIRA, PAOLA
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:
Last Name:MIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 COLUMBIA AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1209
Mailing Address - Country:US
Mailing Address - Phone:213-553-1884
Mailing Address - Fax:213-236-9662
Practice Address - Street 1:515 COLUMBIA AVE FL 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1209
Practice Address - Country:US
Practice Address - Phone:213-553-1884
Practice Address - Fax:213-236-9662
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X
CA89998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program