Provider Demographics
NPI:1306567060
Name:MIRIE, AYSHA RIDA
Entity type:Individual
Prefix:
First Name:AYSHA
Middle Name:RIDA
Last Name:MIRIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 DONOHUE RD
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-4507
Mailing Address - Country:US
Mailing Address - Phone:845-915-0169
Mailing Address - Fax:
Practice Address - Street 1:100 MERRIMACK ST STE 205
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1707
Practice Address - Country:US
Practice Address - Phone:978-455-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA824809044Medicaid