Provider Demographics
NPI:1649973801
Name:COLLINS, MIRA LEE (THW, PSS)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:LEE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:THW, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 NE 47TH AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2221
Mailing Address - Country:US
Mailing Address - Phone:503-704-8403
Mailing Address - Fax:
Practice Address - Street 1:3231 SE 50TH AVE # 1831
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2248
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR108594175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist