Healthcare Provider Details

I. General information

NPI: 1316405665
Provider Name (Legal Business Name): MIRACLE KIDS SUCCESS ACADEMY OF PARAGOULD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 RECTOR RD
PARAGOULD AR
72450-2004
US

IV. Provider business mailing address

1900 STILLWATER DR
JONESBORO AR
72404-9119
US

V. Phone/Fax

Practice location:
  • Phone: 870-932-3600
  • Fax:
Mailing address:
  • Phone: 870-932-3600
  • Fax: 870-932-3611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHELLY KELLER
Title or Position: CEO
Credential:
Phone: 870-761-6680