Healthcare Provider Details

I. General information

NPI: 1538075403
Provider Name (Legal Business Name): MIRACLE KIDS SUCCESS ACADEMY OF TRUMANN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BALCOM LN
TRUMANN AR
72472-9502
US

IV. Provider business mailing address

1005 BALCOM LN
TRUMANN AR
72472-9502
US

V. Phone/Fax

Practice location:
  • Phone: 870-481-0779
  • Fax: 877-481-0779
Mailing address:
  • Phone: 870-481-0779
  • Fax: 877-481-0779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SHELLY A. KELLER
Title or Position: CEO
Credential:
Phone: 870-932-3600