Healthcare Provider Details

I. General information

NPI: 1750203287
Provider Name (Legal Business Name): KATHRYN MIRACLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 BILLINGS HILL RD
BRYANT POND ME
04219-6211
US

IV. Provider business mailing address

63 BILLINGS HILL RD
BRYANT POND ME
04219-6211
US

V. Phone/Fax

Practice location:
  • Phone: 606-282-8774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL8569
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: