Provider Demographics
NPI:1265660617
Name:AHANI, MITRA (MS)
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:AHANI
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 1:127 N SAN MATEO DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2708
Mailing Address - Country:US
Mailing Address - Phone:650-548-1110
Mailing Address - Fax:
Practice Address - Street 1:127 N SAN MATEO DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2708
Practice Address - Country:US
Practice Address - Phone:650-548-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist