Healthcare Provider Details

I. General information

NPI: 1588370464
Provider Name (Legal Business Name): MIRA MEDICAL ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6775 PROSPERI DR
TINLEY PARK IL
60477-4789
US

IV. Provider business mailing address

6775 PROSPERI DR
TINLEY PARK IL
60477-4789
US

V. Phone/Fax

Practice location:
  • Phone: 708-726-6472
  • Fax: 708-671-8446
Mailing address:
  • Phone: 708-726-6472
  • Fax: 708-671-8446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER HIGGINS
Title or Position: PRESIDENT
Credential:
Phone: 708-726-6472