Provider Demographics
NPI:1235428517
Name:MIRACLE, SUSAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:CALLEN-MIRACLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:33 REDFERN DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1651
Mailing Address - Country:US
Mailing Address - Phone:330-759-8215
Mailing Address - Fax:
Practice Address - Street 1:211 REDONDO RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1805
Practice Address - Country:US
Practice Address - Phone:330-744-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA-01612224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant