Healthcare Provider Details

I. General information

NPI: 1124949300
Provider Name (Legal Business Name): LAURA MIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4236 W LINEBAUGH AVE
TAMPA FL
33624-5241
US

IV. Provider business mailing address

4236 W LINEBAUGH AVE
TAMPA FL
33624-5241
US

V. Phone/Fax

Practice location:
  • Phone: 813-442-4027
  • Fax: 813-435-2015
Mailing address:
  • Phone: 813-442-4027
  • Fax: 813-435-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: