Provider Demographics
NPI:1710237060
Name:VALLE-RIESTRA, MIRANDA SUE (MS)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SUE
Last Name:VALLE-RIESTRA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 NE EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5513
Mailing Address - Country:US
Mailing Address - Phone:360-750-7500
Mailing Address - Fax:
Practice Address - Street 1:2500 NE 65TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6812
Practice Address - Country:US
Practice Address - Phone:360-750-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist