Healthcare Provider Details

I. General information

NPI: 1982717385
Provider Name (Legal Business Name): WAYNE MIRACLE ED.D. HSPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 S. LIBERTY ST.
MUNCIE IN
47305-2341
US

IV. Provider business mailing address

413 S. LIBERTY ST.
MUNCIE IN
47305-2341
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-8586
  • Fax:
Mailing address:
  • Phone: 765-288-8586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: