MEDICARE: MIRACAL'S PLACE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1235061102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRACAL'S PLACE LLC

Provider Business Mailing Address
First Line	:	10742 KINGSTON SPRING DR
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-5566
Country	:	US
Telephone Number	:	713-771-1751
Fax Number	:	713-771-1751

Provider Business Practice Location Address
First Line	:	11960 BRAES PARK DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77071-3278
Country	:	US
Telephone Number	:	713-771-1751
Fax Number	:	713-771-1751

Authorized Official
Title or Position	:	CEO
Name	:	NICHOLE ANJANETTE SCOTT
Credential	:	LCCA
Telephone Number	:	713-771-1751

Provider Enumeration Date	:	06/02/2026
Last Update Date	:	06/02/2026

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