Provider Demographics
NPI:1609090356
Name:STRIVELLI, MIRA KATHRYN (LMT)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:KATHRYN
Last Name:STRIVELLI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 FISHER LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-4901
Mailing Address - Country:US
Mailing Address - Phone:850-545-4852
Mailing Address - Fax:
Practice Address - Street 1:1289 CERDAR CENTER DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301
Practice Address - Country:US
Practice Address - Phone:850-942-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 48920171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor