Provider Demographics
NPI:1477930949
Name:MIRLE CHANDRASHEKAR, AVINASH
Entity Type:Individual
Prefix:
First Name:AVINASH
Middle Name:
Last Name:MIRLE CHANDRASHEKAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 DAYBREAK DR APT C
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:91752-6687
Mailing Address - Country:US
Mailing Address - Phone:209-322-6092
Mailing Address - Fax:
Practice Address - Street 1:5725 DARBREAK DR, APT C
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:91752
Practice Address - Country:US
Practice Address - Phone:209-322-6092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 22570235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist