Provider Demographics
NPI:1225420607
Name:MIRACLE, JUSTINE NICOLE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:NICOLE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:NICOLE
Other - Last Name:CUMMINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1333 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2226
Mailing Address - Country:US
Mailing Address - Phone:303-908-4797
Mailing Address - Fax:
Practice Address - Street 1:1333 IRIS AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2226
Practice Address - Country:US
Practice Address - Phone:303-908-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health