Provider Demographics
NPI:1629728332
Name:LOTFALLAH, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:LOTFALLAH
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 1:1765 ALA MOANA BLVD APT 1487
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-1440
Mailing Address - Country:US
Mailing Address - Phone:818-288-7204
Mailing Address - Fax:
Practice Address - Street 1:1426 E 820 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5481
Practice Address - Country:US
Practice Address - Phone:385-309-1038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health