Healthcare Provider Details

I. General information

NPI: 1104757012
Provider Name (Legal Business Name): KATHLEEN C MIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LAS GALLINAS AVE
SAN RAFAEL CA
94903-1843
US

IV. Provider business mailing address

1111 LAS GALLINAS AVE
PETALUMA CA
94954-5421
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-6616
  • Fax:
Mailing address:
  • Phone: 415-491-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: