Provider Demographics
NPI:1952750911
Name:SHIBATA, MIKI DIANE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIKI
Middle Name:DIANE
Last Name:SHIBATA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 Q ST NE
Mailing Address - Street 2:APT 2237
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-2390
Mailing Address - Country:US
Mailing Address - Phone:904-441-0302
Mailing Address - Fax:301-208-6685
Practice Address - Street 1:200 Q ST NE
Practice Address - Street 2:APT 2237
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-2390
Practice Address - Country:US
Practice Address - Phone:904-441-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08162235Z00000X
DCSLP0113235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist