Provider Demographics
NPI:1477058667
Name:MIRAS, BEVERLY JOAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:JOAN
Last Name:MIRAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 FRIARS RD UNIT 339
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2531
Mailing Address - Country:US
Mailing Address - Phone:661-414-6090
Mailing Address - Fax:
Practice Address - Street 1:5400 SHAWNEE RD STE 104
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312
Practice Address - Country:US
Practice Address - Phone:703-256-4830
Practice Address - Fax:703-256-4826
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293304225100000X
VA2305211850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist