Provider Demographics
NPI:1649919622
Name:MIRELES, JONATHAN (MSOT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MIRELES
Suffix:
Gender:M
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TX
Mailing Address - Zip Code:78516-6875
Mailing Address - Country:US
Mailing Address - Phone:956-599-2647
Mailing Address - Fax:
Practice Address - Street 1:508 W GRIFFIN PKWY STE A
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2224
Practice Address - Country:US
Practice Address - Phone:956-583-1527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122724225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist