Provider Demographics
NPI:1881212306
Name:DORIA, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:DORIA
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 1:11040 BOLLINGER CANYON RD STE E
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5056
Mailing Address - Country:US
Mailing Address - Phone:192-555-3426
Mailing Address - Fax:
Practice Address - Street 1:24301 SOUTHLAND DR STE 510
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-1540
Practice Address - Country:US
Practice Address - Phone:925-915-0610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician