Provider Demographics
NPI:1366274532
Name:ALI, MIRIAM THERESA
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:THERESA
Last Name:ALI
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 1:3216 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3318
Mailing Address - Country:US
Mailing Address - Phone:757-610-1643
Mailing Address - Fax:757-673-4607
Practice Address - Street 1:3216 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3318
Practice Address - Country:US
Practice Address - Phone:757-610-1643
Practice Address - Fax:757-673-4607
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982071452Medicaid