Healthcare Provider Details

I. General information

NPI: 1144943416
Provider Name (Legal Business Name): MIRACLE DEYSIA FAN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRACLE BETANCOURT

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26202 OAK RIDGE DR BLDG B204
SPRING TX
77380-1994
US

IV. Provider business mailing address

26202 OAK RIDGE DR BLDG B204
SPRING TX
77380-1994
US

V. Phone/Fax

Practice location:
  • Phone: 346-236-1123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number107417
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: