Provider Demographics
NPI:1083950125
Name:OBETA, MIRACLE (MA, BHRS)
Entity Type:Individual
Prefix:MR
First Name:MIRACLE
Middle Name:
Last Name:OBETA
Suffix:
Gender:M
Credentials:MA, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CIDER MILL LN
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-8843
Mailing Address - Country:US
Mailing Address - Phone:405-541-3733
Mailing Address - Fax:
Practice Address - Street 1:2900 CIDER MILL LN
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-8843
Practice Address - Country:US
Practice Address - Phone:405-541-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health