Healthcare Provider Details

I. General information

NPI: 1679455364
Provider Name (Legal Business Name): MIRACLE TANN LCSW-A
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N MORRIS ST
GASTONIA NC
28052-1739
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-801-8816
  • Fax: 704-866-6105
Mailing address:
  • Phone: 704-874-1904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022591
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: