Healthcare Provider Details

I. General information

NPI: 1114539491
Provider Name (Legal Business Name): SIL-MIRACLE WALKER M.ED., LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 INTERSTATE PKWY # B
AUGUSTA GA
30909-6481
US

IV. Provider business mailing address

3424 PEACHTREE RD NE STE 2200
ATLANTA GA
30326-1156
US

V. Phone/Fax

Practice location:
  • Phone: 706-204-1366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014832
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: