Healthcare Provider Details

I. General information

NPI: 1487028163
Provider Name (Legal Business Name): MIRACLE PLACE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N WASHINGTON ST
BASTROP LA
71220-3842
US

IV. Provider business mailing address

117 N WASHINGTON ST
BASTROP LA
71220-3842
US

V. Phone/Fax

Practice location:
  • Phone: 318-556-3378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA TAYLOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-509-9376