=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215536693
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRACLEWORKS THERAPY & CONSULTING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2020
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 E 14TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-228-5573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 E 14TH ST APT 1008
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-2998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-849-4786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MRS. MIRACLE DONIQUE MONTGOMERY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 310-849-4786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------