Provider Demographics
NPI:1477097632
Name:PATEL, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:PATEL
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:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94042-0816
Mailing Address - Country:US
Mailing Address - Phone:650-996-2214
Mailing Address - Fax:
Practice Address - Street 1:2680 S WHITE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-2074
Practice Address - Country:US
Practice Address - Phone:408-755-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94031106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist