Provider Demographics
NPI:1083162556
Name:MCMILLIAN, MIRACLE
Entity Type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRACLE
Other - Middle Name:
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4505 W JUNIPER DR APT F
Mailing Address - Street 2:
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-1229
Mailing Address - Country:US
Mailing Address - Phone:303-956-7740
Mailing Address - Fax:
Practice Address - Street 1:8540 SCARBOROUGH DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7502
Practice Address - Country:US
Practice Address - Phone:719-630-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13105225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant